Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on June 18 - June 22, 2020 billed with secondary diagnosis code N17.0.  You asked the Plan to pay for the inpatient hospital services billed with secondary diagnosis code N17.0. You say that the records provided support the secondary diagnosis code billed. You say that the enrollee's diagnosis was documented in the medical record by the provider's responsible for the care of the enrollee. You say that the clinical assessment, treatment plan, and care rendered was commensurate with the findings. The Plan denied your request. The Plan says a clinical review of the appeal letter and the documents submitted did not validate N17.0 as the secondary diagnosis for this admission.  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 billed with secondary diagnosis code N17.0. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation supported an admission for Campylobacter Enteritis. The reviewed documentation was unclear regarding a diagnosis of Acute renal failure with tubular necrosis. Even though acute kidney injury was documented as a diagnosis in the Progress Notes and in the Discharge Summary, supporting documentation was not found within the submitted medical record. The enrollee was a then, 76-year-old male with a history significant for hypertension, diabetes, chronic kidney disease, and acute myocardial infarction who presents with a fatigue and generalized weakness, who also reported having profuse diarrhea for few days. The appeal letter notes renal failure with tubular necrosis is based on high creatinine value up to 8.7, caused by hypotension and severe dehydration, which required bicarb drip and bolus fluid. It was noted that enrollee's baseline creatinine is 1.3-1.5 per the Nephrology consult note. Creatinine value of 8.72 and BUN 101 was noted in emergency department. The enrollee was treated with fluids, calcium and magnesium supplementation, and a bicarb drip. It was noted that a gastrointestinal (GI) pathogen array came back positive for Campylobacter, and the enrollee was put on azithromycin. In addition, a computed tomography (CT) stone study was done showing no signs of obstruction. While acute on chronic kidney failure in setting of severe dehydration and hypotension was seen in this enrollee, there was no evidence of acute tubular necrosis. There was no evidence of Urinarysodium greater than 40, FeNA greater than 2%, UA with non-hyaline cases or renal biopsy. The records provided did not support the secondary diagnosis code billed.   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 June 18 - June 22, 2020 billed with secondary diagnosis code N17.0.