Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided on July 25, 2022, to July 27,
2022, billed with principal diagnosis code A41.9 and secondary diagnosis code J96.01.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this
claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met.

Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is a DRG change from 871
(Septicemia or severe sepsis without mechanical ventilation with Major complication or comorbidity) to 194
(Simple pneumonia and pleurisy with complication or comorbidity). The Maximus Reviewer determined that
the documentation supports the billed codes. The reviewer found that the enrollee had hypoxia requiring
supplemental oxygen, with systemic inflammatory response syndrome, and a pulmonary infiltrate, thus meeting
criteria for pneumo-sepsis with respiratory failure, and satisfying diagnosis codes A41.9 (Sepsis, unspecified
organism) and J96.01 (Acute respiratory failure, not elsewhere classified, type 2, with hypercapnia).

The Plan requested a reopen and stated while the enrollee presented with elements of the Systemic
Inflammatory Response Syndrome (SIRS) in the setting of likely pneumonia, complicated by atelectasis, this
patient did not exhibit evidence of life-threatening organ dysfunction related to a dysregulated host response to
infection. Mild relative hypoxia in this case is attributable to the direct impact of pneumonia and atelectasis on
underlying pulmonary function and is not reflective of a dysregulated host response to infection.

The medical records submitted show the enrollee was a then 49-year-old man with a medical history that
included coronary artery disease, valvular heart disease, an ascending aortic aneurysm, stroke, and recent
treatment for pneumonia. The enrollee presented to the hospital on July 25, 2022, with intermittent sharp right
sided pleuritic chest pain. Vital signs were notable for a respiratory rate of 30, and a heart rate of 77. Oxygen
saturation was 90% on room air. The chest X-ray was notable for areas of infiltrate in the right upper lobe and
right lung base; pneumonia could not be excluded. The enrollee was placed on 2 L nasal cannula oxygen. The
enrollee appeared to be in moderate pain/distress at the time of admission. The white blood count was elevated.
It is documented that SIRS criteria were met with elevated heart rate, respiratory rate, and white blood cell
count. The enrollee was treated for community acquired pneumonia, with IV antibiotics and DuoNeb every 6
hours. Nasal oxygen was discontinued, and the enrollee was discharged on July 27, 2022, and was to complete
a course of oral antibiotics. The Plan is correct in this case. The available documentation does not support a
diagnosis of A41.9 (Sepsis, unspecified organism) and J96.01 (Acute respiratory failure, not elsewhere
classified, type 2, with hypercapnia) for the enrollee in this case.

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 care provided on July 25, 2022, to July 27, 2022, billed with principal diagnosis code
A41.9 and secondary diagnosis code J96.01.