Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 8, 2022, to May 
14, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
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 code, N17.0, defined as acute 
kidney failure with tubular necrosis. 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 hospital services at the DRG originally billed. Our reviewer says that the documentation does not 
support the DRG billed. Our physician reviewer found the enrollee presented for evaluation of reported 
worsening abdominal pain, nausea and vomiting for the prior three days. 
 
Emergency Department vital signs included a temperature of 97.9F with a pulse of 80 per minute, blood 
pressure of 144 over97 and respirations of 16/minute with a room air pulse oximetry reading of 99%. The white 
blood cell count was 10.3K/uL with a hemoglobin of 16.1g/dL, hematocrit of 49.3% and platelet count of 
246K/uL. The serum glucose was 109mg/dL. Serum sodium was 144mmol/L with a potassium of 3.4mmol/L, 
total CO2 of 26mmol/L, creatinine of 1.2mg/dL and BUN of 32mg/dL. Urine toxicology revealed the presence 
of Opiate and Cannabinoid. CT scan of the abdomen and pelvis revealed findings suggestive of mild diffuse 
pancolitis. The patient was admitted for further evaluation and management, receiving intravenous hydration, 
antiemetic medication, intravenous antibiotics, oral Vancomycin and bowel rest. Urinalysis on May 10, 2022 
revealed 1-plus protein. The enrollees serum creatinine level was 1.2mg/dL, with a BUN of 32mg/dL, on May 
8, 2022. Serum chemistry studies were not obtained on May 9, 2022. The serum creatinine level was 1.4mg/dL, 
with a BUN of 20mg/dL, at 03:40 hours on May 10, 2022. On May 11, 2022, at 05:19 hours, the serum 
creatinine level was 1.0mg/dL, with a BUN of 22mg/dL. The serum creatinine level was 0.9mg/dL, with a 
BUN of 15mg/dL, on May 12, 2022; 0.9mg/dL, with a BUN of 11mg/dL, on May 13, 2022; and 1.1mg/dL, 
with a BUN of 9mg/dL, on May 14, 2022, the day of discharge. Urine chemistry studies were not obtained 
during the hospital stay. 
 
Per Medscape Internal Medicine, Acute kidney injury (AKI) is a clinical syndrome manifested by a rapid or 
abrupt decline in kidney function and subsequent dysregulation of the body electrolytes and volume, and 
abnormal retention of nitrogenous waste. The widely accepted Kidney Disease: Improving Global Outcome 
(KDIGO) definition of AKI is based on the change of serum creatinine and urine output, as follows: Rise in 
serum creatinine equal to 0.3 mg/dL within 48 hours Rise in serum creatinine equal to 1.5 times baseline, 
which is known or presumed to have occurred within the prior seven days Urine output less than 0.5 
mL/kg/hour for six hours. In this case, there was no clinical or laboratory evidence of acute renal failure. The 
review has determined that the documentation does not support secondary diagnosis Acute kidney failure with 
tubular necrosis (N17.0).  
 
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 inpatient hospital services provided on May 8, 2022, to May 14, 2022, at the Diagnosis Related Group 
(DRG) originally billed.