Benjamin Gem: A Case Study

a glance). Mrs. Zwick should go to a Medicare Network pharmacy to minimize cost. The

“This article discusses how Medicare Carriers and Fiscal Intermediaries use coverage determinations to establish medical necessity. When the condition(s) of a patient are expected to not meet medical necessity requirements for a test, procedure, or service, the provider has the obligation under the

Gigantism is abnormally large growth during childhood caused by excess growth hormone secreted by the anterior pituitary gland.

“The medical necessity criteria for coverage have not been met in this case. As a result, we are unable to

First, I must assess Mrs. Jones understanding of her insurance plan. Is she even aware that she doesn 't have prescription drug coverage? According to Cohen and Villarroel (2015), "approximately one fifth (18%) of the $263 billion spent on retail prescription drugs in the United States in 2012

The carrier has denied coverage of Harvoni 90mg – 400mg as not medically necessary. There is a letter from the carrier to the member dated 11/20/2015, which states in part:

* Medicare/Medicaid, to be sure the doctor is not banned from caring for Medicare/Medicaid patients

All three providers have agreed that prescribing a pharmacologic and non-pharmacologic treatment regimen must result from clinical judgment based on a thorough assessment of the patient and the patient’s environment, present and past medical history, current home medication, the determination of differential diagnosis and appropriate diagnostic procedure, a review of potential alternative therapies and specific knowledge about the drug chosen and the disease process it is designed to treat (Woo & Robinson, 2016; p.6).

Pursuant to sections 1128 and 1156 of the Social Security Act, the OIG has the authority to exclude individuals and entities from Federally funded health care programs, like Medicare and Medicaid. The paramount effect of exclusion is that payment is prohibited for items or services that an excluded individual or entity provides. This prohibition extends to anyone who chooses to employ or contract with an excluded individual or entity. Providers who violate this prohibition, are required to pay back any and all Federal funds inappropriately received and may also be subject to civil monetary penalties (“CMP”).

Medicare law permits installment just for administrations or supplies that are viewed as sensible and meaningful for the expressed finding. Medicare won't cover systems regarded to be a trial in nature. There are cases in which the supplier verifies that medications or administrations are ultimately advocated, and such treatment choices are then disclosed to the patient, who must pay the full cost of the non-secured system.

Omnitrope is an intravenous injection used in the treatment of Prader-Willi Syndrome, or PWS. PWS, is a genetic condition which disturbs many growth developments in the body. This condition is nominally characterized by hypotonia – a syndrome classified by weaker or reduced muscle tone, developmental growth problems, developmentally delaying features, and difficulties in feeding. The drug is used to treat both children and adult patients displaying these physiognomies.

Every parents thinks about how tall their child is going to be. This is determined by the amount of sleep your child gets while the are young. Sleep is the most important factor to children's growth. The key to human growth is HGH (Human Growth Hormone). This Hormone is released the most during sleep, and it is the key factor to growth. Without the correct amount of sleep growth problems will occur because of the shortage of HGH. This can lead to Heart disease, kidney disease, high blood pressure, diabetes, and stroke. Some children fail to produce the correct amount of HGH during the day and without the right amount of sleep these children have problems growing. Many around the world would argue that the problem could be fixed with

The juvenile onset of this disease is referred to as gigantism, and has a slightly different mechanism in comparison to acromegaly. Gigantism and acromegaly both are the result of growth hormone hypersecretion. Gigantism causes overgrowth of long bone whereas acromegaly does not stimulate long bone growth but cancellous growth and broadening of extremities and facial features. The physical appearance changes in an individual can be key indicators for acromegaly; confirming the diagnosis is completed by analysis of growth hormone and IGF concentration levels in the blood. Once acromegaly is confirmed, there are various treatment options available for patients including surgery, radiation and medication. There are still many unanswered questions about acromegaly, creating a wide area of research needing to be completed in order to better diagnosis and treat the

Pituitary Dwarfism is a disease where the growth of someone is slowed or delayed, usually due to a malfunction in the pituitary gland and it results in a less than normal stature. It takes place in the pituitary gland which regulates the production of hormones and it causes normal stature with short limbs. Since the height and growth is decreased, it results in what many people refer to as a “midget.” The Pituitary gland produces many hormones such as the growth hormone, luteinizing, thyroid, prolactin, follicle-stimulating, and oxytocin. A decrease in the production of hormones in the anterior pituitary is what causes most forms of dwarfism. The decrease occurs during childhood, and it causes the body to be developed proportionately, but at

The shape of the skull assessed, and it felt symmetric and smooth. It was normocephalic and appropriate to the body size. During this body part assessment, the forehead, the side of each parietal bone, the occipital bone, and the mastoid process behind each were assessed at the cranial bone which had the normal protrusions. Also, there was no tenderness to the palpation. During this examination, the patient skull was intact without any abnormally noted in the skull. The abnormally of the skull can be seen in the hydrocephaly an excessive accumulation of fluid in the head, in the Paget’s disease, and in the acromegaly which causes by excessive secretion of growth hormone from the pituitary