Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 14, 2022 at 
the Diagnosis Related Group (DRG) 180 originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG 180 originally billed. You say that the 
medical records support the diagnosis codes billed. The Plan denied your request. The Plan says after a 
thorough review of all the information in the submitted medical record, the review did not find sufficient 
documentation to clinically validate the diagnosis of I21.A1 (Myocardial infarction type 2). The patient was 
asymptomatic and there was no evidence of new ischemic changes on EKG. There was also insufficient 
documentation to validate code C34.32 (Malignant neoplasm of lower lobe, left bronchus or lung) as the 
principal diagnosis. Based on the clinical evidence and coding guidelines E86.0 (Dehydration) is the most 
appropriately principal diagnosis assignment. This recommendation results in a change from DRG 180 to DRG 
640. The decision to remove code I21.A1 (Myocardial infarction type 2) and to replace code C34.32 
(Malignant neoplasm of lower lobe, left bronchus or lung) with E86.0 (Dehydration).  
 
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 diagnosis I21.A1, Myocardial infarction type 2. 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 
180 originally billed. Our reviewer says that the DRG billed is not appropriate. Our physician reviewer found 
per the reviewed documentation, the enrollee presented to the facility on August 14, 2022 with complaints of 
low blood pressure and dizziness. The past medical history was significant for congestive heart failure, (CHF), 
chronic obstructive pulmonary disease (COPD) with dependence on supplemental oxygen, diabetes, 
hypertension, and stage III lung cancer. The enrollee was currently on his second round of chemotherapy and 
radiation. Vital signs in triage noted a temperature of 98.2, heart rate of 79, respiratory rate of 22, blood 
pressure of 120/72, and SpO2 of 96% on 2L nasal cannula. In the emergency department (ER), the physical 
exam was relatively benign. Laboratory work-up showed a white blood cell count of 0.7, platelet count of 26, a 
hemoglobin of 8.6, and a troponin of 1.1. The enrollee was admitted for serial troponin levels and further 
medical management as needed. Per Medscape Internal Medicine, Type 2 myocardial infarction (MI) is defined 
by a rise and fall of cardiac biomarkers and evidence of ischemia without unstable coronary artery disease 
(CAD), due to a mismatch in myocardial oxygen supply and demand. Myocardial injury is similar but does not 
meet clinical criteria for MI. There is uncertainty regarding clinical characteristics, management and outcomes 
of type 2 MI and myocardial injury in comparison to type 1 MI In this case, the enrollee was asymptomatic and 
there was no evidence of new ischemic changes on EKG. The review has determined that the documentation 
did not support the diagnosis I21.A1 (Myocardial infarction type 2). 
 
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 August 14, 2022 at the Diagnosis Related Group (DRG) 180 
originally billed.