Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 17, 2022, 
to November 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
diagnosis codes A41.01, E43, and Z68.25 are supported in the record, therefore the claim should be paid at the 
DRG originally billed. The Plan denied your request. The Plan says A41.01, E43, and Z68.25 are not supported 
in the record. 
 
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 principal diagnosis A41.01, defined as sepsis due to 
Methicillin susceptible Staphylococcus aureus, secondary diagnosis E43, defined as unspecified severe protein-
calorie malnutrition, and secondary diagnosis Z68.25, defined as body mass index of 25.0-25.9, adult. 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 at the DRG 
originally billed. Our reviewer says that principal diagnosis A41.01, secondary diagnosis E43, and secondary 
diagnosis Z68.25 are not supported in the documentation. Our physician reviewer found the enrollee was 
treated in the hospital for right knee swelling and pain after having fallen 3 times over the prior 2 days. Workup 
showed leukocytosis in the serum and joint fluid. Antibiotics and fluids were given. The enrollee had oxygen 
saturation of 93% on room air, no abnormal arterial blood gas results, creatinine level of 1.19 which reduced 
after fluids, bilirubin 1.2, and a Glasgow Coma Scale (GCS) score of 14. Although low blood pressure and a 
small rise in creatinine were noted immediately following surgery, these would be expected and were not 
clearly attributable to the enrollee's infection. The enrollee had dementia at their baseline, explaining the GCS 
score of 14. It was not clear from the documentation that bilirubin of 1.2 was not the enrollees baseline. Based 
on insufficient sequential organ failure assessment (SOFA) points to suggest organ damage was directly related 
to a dysregulated response to systemic infection, the Sepsis 3 criteria is not met. Therefore A41.01 is not 
supported. There was report of poor oral intake for 1 week prior to hospitalization with noted muscle wasting 
of the temples, clavicles, and calves. Albumin was 1.9. It was reported that the enrollee was eating 50% or less 
the week prior. Body Mass Index (BMI), however, was 25.5 (overweight). Based on the Global Leadership 
Initiative on Malnutrition (GLIM) guidelines, which require a lower BMI, the secondary diagnosis E43 is not 
supported. Although the enrollee had a BMI between 25-25.9, this factor was not clinically significant or 
related to the enrollee's condition or treatment during this admission. Therefore, the secondary diagnosis 
Z68.25 is not supported.  
 
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 November 17, 2022, to November 25, 2022, at the Diagnosis 
Related Group (DRG) originally billed.