Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from February 2, 2021, to 
February 4, 2021, as billed with Diagnosis Related Group (DRG) 291. 
 
You asked the Plan to pay for inpatient care billed with DRG 291. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 291 is not supported as the diagnoses of respiratory failure with acute hypoxia (J96.01) and acute kidney failure with 
tubular necrosis (N17.0) are not supported in the medical record. The Plan argues that DRG 292 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 291. Our 
reviewer says that the diagnoses of respiratory failure with acute hypoxia (J96.01) and acute kidney failure with 
tubular necrosis (N17.0) are not supported in the record for this inpatient admission. Our physician reviewer 
found that the enrollee was sent to the emergency room from the nursing home. The enrollee has a past medical 
history of atrial fibrillation, coronary artery disease, diabetes mellitus, diverticulitis, obesity, ventricular 
tachycardia and ischemic cardiomyopathy. The enrollee noted that he did not know why he was sent to the 
emergency department (ED). The enrollee possibly had some shortness of breath, but it is unclear as to the 
duration. Upon arrival to the ED, the enrollee was afebrile, hypotensive, with a normal hearth rate, but did have 
some hypoxia. Family of the enrollee noted that he had been declining recently in the last months. The 
physician noted that the enrollee was admitted from the nursing home due to an increasing lower extremity 
edema and weight gain of about 30 pounds despite initiation of a diuretic a week ago. The enrollee was also 
noted to be hyponatremic and was initially started on Lasix infusion for volume overload, however he became 
hypotensive and therefore Lasix was held. The enrollee reported fatigue and dyspnea. Palliative care was 
discussed with the family. Progress notes suggested severe symptomatic hypotension most likely hypovolemic 
due to diuresis, acute decompensated on chronic heart failure with reduced ejection fraction, acute hypoxic 
respiratory failure due to congestive heart failure, acute kidney injury likely contributing to hyperkalemia also 
likely due to heart failure with possible acute tubular necrosis (ATN). Though enrollee had a decreased oxygen 
saturation on some occasions during the admission, treatment was not consistent with that of acute respiratory 
failure such as supplemental oxygen greater than 5 liters. Regarding ATN, we acknowledge there was an 
increased level of Creatinine during the admission; however, there was no evidence of urinalysis with non-
hyaline casts, fractional excretion of sodium >2%, or urinary sodium >40 mEq/L. Renal biopsy was also not 
noted in the record to confirm the diagnosis of ATN. The review has determined that the medical records did 
not support the billing of respiratory failure with acute hypoxia (J96.01) and 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 that 
Medicare rules for coverage of inpatient care billed with DRG 291 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from February 2, 2021, to February 4, 
2021, as billed with Diagnosis Related Group (DRG) 291.