This series, “The Honne of the Examiners,” is a series in which current and former examiners of payment examination organizations take up cases in which they had difficulty in reviewing claims, and share what they felt from their experiences.
this issue
Information on the causative disease was insufficient.
Some drugs are covered by insurance only after having two disease names
Judo, which is an Olympic event that originated in Japan, has a rule called “Awase-waza” in which a person who has been judged as having a technique is considered to have taken one by being judged as having a technique again.
Regarding the indications of drugs used in medical insurance, there are drugs in a similar situation. In other words, there are drugs that are recognized as insurance coverage only after having two disease names.
It was a recipe that I felt that I was paying attention to the description
Receipts containing calcium polystyrene sulfonate (CPS) oral jelly have been reviewed. The name of the disease clearly stated “hyperkalemia”, and the K value was also added in the comment column, which showed that he was careful about the description of the claim (Note: Note that the K value is not mandatory).
However, the causative disease of hyperkalemia was not listed in the disease name column, so I did not know. The efficacy of CPS oral jelly is “hyperkalemia associated with acute or chronic renal failure”. In other words, the use of this drug is not approved under medical insurance unless there are “acute or chronic renal failure” and “hyperkalemia” as disease names.
If the cause of hyperkalemia is not kidney failure, the cause should be investigated. In the case of overdose of K, the condition can often be improved with dietary guidance alone. If an endocrine-metabolic disorder is involved, further investigation and treatment of the causative disorder is required. Hyperkalemia that is not caused by acute (chronic) renal failure is inappropriate for the prescription of CPS oral jelly. It can be said that there are hidden hints that lead to appropriate medical treatment in the efficacy effect.
There is no “judgment victory” in insurance medical treatment
Unlike judo, insurance medical treatment does not win by decision with just one wazaari. There is no way to accept half the score because there is only half the name of the disease. Please take a careful look at the efficacy effect and respond.
The point of this time
It should be confirmed once again whether or not the name of the disease for the recognized efficacy and effect is sufficient and described.
Judge: Nekokichi Okuma
A surgeon working at a city hospital, he has about 10 years of experience in insurance reviews. He cherishes the words, “Motivation is good or selfish.”
2023-06-25 22:01:43
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