Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for diagnosis code D61.818-Other pancytopenia. We decided that the 
Plan does not have to pay for diagnosis codes A41.9, J18.9, J44.0 and R65.20.  
 
You asked the Plan to pay for inpatient hospital services provided on July 20, 2021, to July 23, 2021, at the 
Diagnosis Related Group (DRG) originally billed.. You say that the services are supported. The Plan says that 
the services are not supported. 
 
We decided that the Plan has to pay for diagnosis code D61.818-Other pancytopenia.  
 
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 D61.818-Other pancytopenia. 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 for this diagnosis code. Our reviewer says that the denial of D61.818-
Other pancytopenia should be overturned. Laboratory studies show pancytopenia, likely due to poor 
health/nutrition, which was in part managed with the administration of folate and thiamine. 
 
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 hospital services have been met. Therefore, we decided that the Plan 
has to pay for diagnosis code D61.818-Other pancytopenia.  
 
We also decided that the Plan does not have to pay for diagnosis codes A41.9, J18.9, J44.0 and R65.20. 
 
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 A41.9-Sepsis, unspecified organism, J18.9- 
Pneumonia, unspecified, J44.0-Chronic obstructive pulmonary disease with (acute) lower respiratory infection 
and R65.20-Severe sepsis without septic shock. 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 these 
diagnosis codes. Our physician reviewer found the denials of A41.9, J18.9, J44.0 and R65.20 should be upheld. 
While there was initial concern that the enrollee may have had a respiratory infection/pneumonia, upon 
evaluation no evidence of infection/pneumonia was found. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnosis codes A41.9, J18.9, J44.0 and R65.20 have not been met. Therefore, 
we decided that the Plan does not have to pay for diagnosis codes A41.9, J18.9, J44.0 and R65.20. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.