First of all: I do not represent the legal opinion of the Federal Social Court, I am only trying to make it understandable here in this blog.
Potential is not the same as potential
The Federal Social Court ruled in two rulings on April 24.04.2018, 137 on the compatibility of inpatient liposuction for lipoedema with the quality requirement according to the Social Code V (SGB V), which is decisive for the statutory health insurance companies for the granting of benefits. After these decisions, the hope of inpatient liposuction for lipedema has also been dashed; Up to now, the norm of Section 3 c (XNUMX) SGB V has offered a very good starting point for asserting and applying for surgical therapy for lipedema. According to this provision, a positive recommendation by the Federal Joint Committee for such new examination and treatment methods as liposuction for lipedema is not required if the treatment in question is medically indicated and offers the potential of a necessary treatment alternative.
In its announcement on the suspension of the method evaluation of July 20.07.2018, XNUMX, the Federal Joint Committee had also spoken of the "potential of a necessary treatment alternative".
Quality requirement and economy principle of the GKV
It must be taken into account that only those methods should be financed in statutory health insurance that have been adequately researched (quality and economic efficiency requirement of the statutory health insurance). However, in the case of liposuction for lipedema, there is a large gap between the therapeutic approaches practiced every day across the country by the various surgeons, be it privately or in an approved hospital, and the current status of the service catalog.
In this respect, the BSG judgments may be legally and logically understandable, but in the actual sense and from the patient's point of view, this should not be plausible.
And a place in the study?
The fact that, according to one of the above-mentioned BSG judgments, the entitlement to participate in the GBA study does not change anything in this respect. This was described in a post frequently posted on FB in April. Because: Here there is only a right to exercise an error-free judgment by the health insurance company. Nicht but on one place in the study itself. The number of places is very limited and only covers a minimal part of the patient group.
BSG judgments - meaning for us patients
In summary, it can be said that a legal claim to liposuction in the case of lipedema in a so-called “contract hospital” can no longer be legally enforced. All that remains is the possibility of fictitious approval and a small number of individual decisions, the logic of which is neither comprehensible nor transparent.
The judgments of the BSG leave all lipedema patients perplexed and shocked; the human component is of considerable importance.
In the days following these two judgments, I was in close contact with a large number of my clients and other patients. There have been many reactions, some of which are worrying, which are not always easy even for a lawyer.
However, it would be wrong here to bury your head in the sand or to say to yourself:
There's no point in any of this anyway.
In the next few posts I will show you further possibilities to find formal starting points. Or even once in ways to get more involved in the health policy process in general.
With this in mind, more about this and many other topics on this blog,
Your Ruth Leitenmaier
You can find more articles on the legal situation of lipedema patients here.
very good report, thank you for that.
Unfortunately, the devil of mistakes has crept in.
“The Federal Joint Committee also spoke of the“ potential of a necessary treatment alternative ”in its announcement on the suspension of the method evaluation of July 20.07.2018, XNUMX.
Here it should read —–> July 20.07.2017, XNUMX!
Hello Silvia, thank you very much for your watchful eye, we will correct that.