Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 10, 2021, to July 
17, 2021, as billed with Diagnosis Related Group (DRG) 602. 
 You asked the Plan to pay for inpatient care billed with DRG 602. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 602 is not 
appropriate as the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical record. The 
Plan argues that DRG 603 is more appropriate in this case. 
 
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. 
 
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 inpatient care billed with DRG 602. Our 
reviewer says that the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that the enrollee presented to an outside hospital 
after sustaining a fall at home with weakness and hypotension. She had bilateral lower extremity edema with 
erythema concerning for cellulitis as well as leukocytosis. She was also found to have acute kidney injury with 
Creatinine 1.6-1.7, hyponatremia with sodium 121, anemia with hemoglobin (hgb) of 7, and was in controlled 
atrial fibrillation. She was given intravenous antibiotics (IVAB) and transferred to the intensive care unit for 
potential pressor requirements. She was transferred to the billing hospital to be evaluated for possible heart 
failure exacerbation. Heart failure was considered, assessed, and ruled out. She also presented with bacteremia 
of an unclear source, although she did have an infection of cellulitis. She was initially stated to be septic, but a 
diagnosis of sepsis appeared to be in question throughout the context of the record and was not a billed 
diagnosis. Due to low hgb, her Eliquis was held, and she was evaluated by gastroenterologist. Further 
diagnostics revealed Barrett's esophagitis with no source of bleeding found despite five episodes of melena. 
She was continued on IVAB for bilateral lower extremity cellulitis, evaluated by wound care for wounds, and 
underwent lower extremity arterial duplex with no significant high-grade stenosis. Physical therapy and 
occupational therapy found the enrollee to be deconditioned and recommended discharge to a skilled nursing 
facility (SNF), which was the enrollees discharge disposition. While it is acknowledged that a presentation of 
weakness could be considered in a diagnosis of metabolic encephalopathy, this should also be supported by 
abnormal neurological examination findings documented by the provider. The enrollee was noted to be 
deconditioned with a history of failure to thrive. It was also stated by the physician that the enrollees initial 
presentation of weakness was most likely due to a gastrointestinal bleed in setting of adult failure to thrive. Her 
weakness was stated to resolve with treatment for multiple comorbidities. However, there was no evidence of 
an abnormal neurological examination. Neurological exams throughout the record stated, "patient awake and 
alert, opening eyes spontaneously, PERRLA [pupil, equal, round, reactive to light and accommodation], 
following commands, speech fluent and coherent, moving all 4 extremities, cranial nerves grossly intact, motor 
and sensory grossly intact b/l [bilateral]" as well as "no focal deficits". Without documentation of abnormal 
neurological findings by the provider, a presentation of weakness alone, even if etiologies can be inferred from 
the above-mentioned comorbidities, does not validate a diagnosis of metabolic encephalopathy. The review has 
determined that the medical records support the billing of metabolic encephalopathy (G93.41). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 602 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from July 10, 2021, to July 17, 2021, as 
billed with Diagnosis Related Group (DRG) 602.