Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the inpatient services provided on May 27, 2021, to June 8, 2021, billed 
with diagnosis code A41.59. We decided that the Plan does not have to pay for the inpatient services billed 
with diagnosis code A41.59 and E43.  
 
You asked the Plan to pay for the inpatient services as billed. You say that medical records submitted supports 
diagnosis codes A41.59 and E43 and should be paid. The Plan says that they did not find sufficient 
documentation to clinically validate the diagnoses of A41.59 (Other gram-negative sepsis) and E43 
(Unspecified severe protein-calorie malnutrition). The enrollee had a sepsis score of 0 and the phenotypical 
criteria were not met for severe malnutrition. 
 
We decided that the Plan has to pay for the inpatient services provided on May 27, 2021, to June 8, 2021, 
billed with diagnosis code A41.59.  
 
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 the inpatient services provided on May 27, 
2021, to June 8, 2021, billed with diagnosis codes A41.59 and E43. Our physician reviewer found that the 
medical records showed the patient had Systemic Inflammatory Response Syndrome (SIRS) criteria with fever 
and leukocytosis, and culture positive gram-negative bacteria, therefore, A41.59 is supported. There is no 
objective documentation that was submitted to support severe malnutrition to justify secondary code E43.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sepsis (A41.59) and severe protein-calorie malnutrition (E43) have not been 
met. Therefore, we decided that the Plan has to pay for the inpatient services provided on May 27, 2021, to 
June 8, 2021, billed with diagnosis code A41.59.  
 
We also decided that the Plan does not have to pay for the inpatient services provided on May 27, 2021, 
to June 8, 2021, billed with diagnosis code A41.59 and E43.  
 
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. 
 
As noted in the above physician review, the records did not support the secondary diagnosis code E43. Based 
on this information, we decided that Medicare rules for coverage of the services billed with diagnosis code 
A41.59 and E43 have not been met. Therefore, we decided that the Plan does not have to pay for to pay for the 
inpatient services provided on May 27, 2021, to June 8, 2021, billed with diagnosis code A41.59 and E43.  
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.