Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services billed with secondary diagnosis of E43 (Unspecified, severe protein calorie malnutrition) provided from January 8, 2021 to January 15, 2021.  

You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.   

In this case, you billed the inpatient services provided with secondary diagnosis of E43 defined as unspecified, severe protein calorie malnutrition. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient services. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer found the documentation supports an admission for further evaluation and treatment of obstructive jaundice for which an Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stent insertion was performed. The documentation was reviewed for clear and consistent provider documentation of severe protein calorie malnutrition, evidence, and documentation of both phenotypic and etiologic characteristics consistent with severe malnutrition as well as provider documentation of the enrollee's nutrition specific interventions to address this condition during the encounter. The progress note documentation described the enrollee as cachectic and malnourished with an enrollee report of decreased appetite since cancer diagnosis, feeling of fullness after consuming small meals and recent good appetite prior to admission. Nutrition consult documentation indicated inadequate energy intake with less than 75% energy requirement intake for more than one-month, significant weight loss with 22% weight loss over one year with mild subcutaneous fat loss to orbital and buccal areas, mild temporalis muscle loss and BMI 19.4. Nutrition recommended a diet with adequate protein and energy intake to prevent further weight loss, monitoring of weight and nutrition-related labs, assessment of folate and B12 levels, and oral supplement drinks twice a day once diet allowed. While the progress notes indicated encouragement of oral intake, the documentation received was incomplete to reflect provider documentation addressing the specific interventions or significance of the nutrition consult recommendations. Therefore, the secondary diagnosis of E43 was not supported by the documentation.   

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services billed with secondary diagnosis of E43 (Unspecified, severe protein calorie malnutrition) provided from January 8, 2021 to January 15, 2021.