Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the inpatient services billed with the DRG calculated with diagnosis 
code A41.51. We decided that the Plan does not have to pay for the inpatient services billed with the DRG 
calculated with diagnosis code R65.20.  
 
You asked the Plan to pay for inpatient hospital services provided on September 11, 2022, to September 15, 
2022, at the Diagnosis Related Group (DRG) originally calculated with diagnosis codes A41.51 and R65.20.. 
You say that the documentation supports the billed diagnosis codes. The Plan says that the billed diagnosis 
codes are not supported. 
 
We decided that the Plan has to pay for the inpatient services billed with the DRG calculated with 
diagnosis code A41.51.  
 
The Plan follows 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 billed with the DRG 
calculated with diagnosis code A41.51. Our reviewer says that the billing of primary diagnosis code A41.51 is 
supported. Our physician reviewer found the provided documentation from these dates describes the enrollee as 
being treated for a urinary tract infection (UTI) and possible pneumonia with intravenous (IV) antibiotics and 
IV fluids. The documentation does support the primary diagnosis A41.51 (Sepsis due to Escherichia coli [E. 
coli]).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient services billed with the DRG calculated with diagnosis code 
A41.51 have been met. Therefore, we decided that the Plan has to pay for the inpatient services billed with the 
DRG calculated with diagnosis code A41.51.  
 
We also decided that the Plan does not have to pay for the inpatient services billed with the DRG 
calculated with diagnosis code R65.20. 
 
The Plan follows 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 billed with the DRG 
calculated with diagnosis code R65.20. Our reviewer says that the secondary diagnosis code R65.20 has not 
been supported. Our physician reviewer found there is insufficient evidence to support the secondary diagnosis 
R65.20 (Severe sepsis without septic shock). The enrollee presented with fever, cough, fatigue, and headache 
as well as reporting intermittent hallucinations, agitation, and confusion thought to be new and related to the 
infection. Blood pressure was initially low and was still occasionally low even after initial IV fluids. The 
reviewer found that the enrollee's Glasgow coma scale (GCS) was 14 initially. Platelets, bilirubin, and 
creatinine were each normal. Based on the clinical presentation, the patient had a sequential organ failure 
assessment (SOFA) score of 2 (decreased mental status and MAP<70 after fluids) meeting Sepsis 3 criteria for 
sepsis but not showing other signs of severe sepsis such other organ damage.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient services billed with the DRG calculated with diagnosis code 
R65.20 have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient services 
billed with the DRG calculated with diagnosis code 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.