Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on April 30, 2022, to 
May 4, 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 the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
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 code I13.0, described as 
hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney 
disease, or unspecified chronic kidney disease, and secondary diagnosis codes I50.43, described as acute on 
chronic combined systolic (congestive) and diastolic (congestive) heart failure, N17.0, described as acute 
kidney failure with tubular necrosis, G93.41, described as metabolic encephalopathy, E43, described as 
unspecified severe protein-calorie malnutrition, G45.9, described as transient cerebral ischemic attack, 
unspecified, and Z20.822, described as contact with and (suspected) exposure to COVID-19. 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 documentation does not support the billed codes. Our physician reviewer found the 
enrollee is an 81-year-old male who presented to the emergency department with weakness/fatigue. He was 
alert without distress. Workup revealed no evidence of infection or ischemia but was given fluids for 
dehydration and antibiotics empirically. He developed high blood pressure that was controlled with medication 
and renal function improved. Kidney function was due to dehydration improved with fluids in the setting of 
chronic kidney disease. There was no direct evidence of tubular necrosis on urinalysis results. There was no 
documentation of the patient having symptoms or signs of encephalopathy. There was insufficient evidence to 
support malnutrition as there was no report of significant weight loss, muscle wasting, underweight status, or 
prolonged decreased oral intake. Workup (physical findings, imaging) did not reveal evidence of recent stroke. 
The patient did not have significant elevations in respiration rate, heart rate, temperature, or white blood cell 
count to suggest Systemic inflammatory response syndrome. Therefore, the documentation does not 
sufficiently support the following diagnoses:  I13.0, I50.43, N17.0, G93.41, E43, G45.9, and Z20.822.  
 
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 April 30, 2022, to May 4, 2022, at the Diagnosis Related Group 
(DRG) originally billed.