GLIM criteria as basis for UHC denial for SPCM

Hi everyone,

We received our first SPCM denial based on GLIM criteria from UHC, curious to know if anyone else have received any at their facility.

Reviewer Rationale:

A clinical validation review based upon clinical criteria was performed on this claim.

As indicated by Coding Clinic 4th Q 2016, a payer may use a specific clinical definition or set of

criteria when establishing a diagnosis. After reviewing the medical record for clinical validation of

unspecified severe protein calorie malnutrition sufficient supporting documentation was not found

within the submitted medical record to validate this diagnosis.

Although the diagnosis of unspecified severe protein calorie malnutrition is documented in physician

query, sufficient supporting documentation was not found within the medical record to validate this

diagnosis based on clinical criteria.

The following criteria were not supported. The patient had no weight loss greater than 10% within the

past 6 months OR greater than 20% beyond 6 months. The patient's BMI was not less than 20.

Patient did not have severely reduced muscle mass.

Secondary diagnosis code E43 was removed from the claim consistent with the documentation that

was received.

Please reference AHA Coding Clinic 4th Q 2016 pgs. 147-149 which addresses that payors may

require a specific clinical definition/criterion to establish a diagnosis.

Please also reference:

Jensen GL, Cederholm T, Correia MITD, et al. (2019). GLIM Criteria for the Diagnosis of

Malnutrition: A Consensus Report from the Global Clinical Nutrition Community. JPEN J Parenter

Enteral Nutr, Vol 43 (1) 32-40.

Optum has performed a DRG review of the case referenced above. After a thorough review of the

documentation provided by your facility, we've determined that the claim was overpaid.

Cynthia Mead RN CCDS

Northern Arizona Healthcare

cynthia.mead@nahealth.com