Good to know · During a cannabis therapy
You are interested in applying for the assumption of costs in connection with a cannabis therapy under Section 31 (6) SGB V with your statutory health insurance fund. We have compiled some information on this page for you.
Background
LGP cooperates with a small number of specialist physicians who hold statutory health insurance accreditation and specialise in therapy with cannabinoids, working in their own practices. Among physicians in private practice, the general willingness to deal with applications for the assumption of costs for cannabis medicines under SGB V is low and a difficult topic. Only very few specialist physicians with statutory health insurance accreditation are prepared at all to engage with this challenging subject or to join a specialised network such as LGP. This is due to the complex, time-consuming application procedure and the immense risk of subsequent recourse claims by the health insurance funds at the expense of the prescribing statutory health insurance physicians. Recourse claims are penalty payments that statutory health insurance physicians must make to the health insurance funds in the case of uneconomical treatment.
Nevertheless, the topic of the assumption of costs is very important to LGP for the benefit of our patients. We are therefore glad to be able to assist you here as well, with our small and highly specialised team of experienced experts. Please note, however, that interest in obtaining the assumption of costs is very high among our patients. Considerable waiting times must therefore be expected when processing matters relating to the assumption of costs. We always strive to handle your request as quickly as possible, but always competently and with the necessary care. Due to the extremely high demand, however, this currently requires patience.
How it works
In the LGP patient portal you will find the menu item "Optional Service". This page also contains our service "Screening for the assumption of costs". When booking, you first complete a questionnaire that covers all the important aspects of your situation with regard to the application for the assumption of costs. We then assign your screening order to one of our specialised physicians. You will be notified of this by email and must then conclude the corresponding fee agreement digitally via the patient portal. You will then receive your invoice for the screening by email. You can also view and pay it via the patient portal. Once payment has been received, the screening order is submitted to your physician. Your physician then assesses, on the basis of the currently available medical documents and information, the possible likelihood of success of an application for the assumption of costs with your statutory health insurance fund.
Once your physician has issued the screening assessment, you can download it in the LGP patient portal. As soon as it is available, you will be notified by email. On the basis of this assessment and further information, you can then decide for yourself whether you would first like to compile additional documents/findings/evidence etc., or whether you would like to proceed directly with the application process for the assumption of costs.
You now have the option of booking an available appointment with one of our cooperating specialist physicians in private practice with statutory health insurance accreditation for the application to your statutory health insurance fund. The booking is made via the LGP patient portal. Please note that this appointment takes place on site at one of our specialist physicians in private practice.
After logging in to the LGP patient portal, you will find the menu item "Assumption of costs". From this page you start the application process and book your on-site appointment. Once you have booked your individual appointment, you will receive an email with all further information on the application procedure for the assumption of costs. This email also contains the address of the practice of your treating specialist physician. A physical/internal examination, the taking of a medical history and, if necessary, a laboratory test or further diagnostics will then be carried out on site at the practice, as required. Together, the application documents are then worked out in detail on site for the final submission to your health insurance fund. As soon as your physician has completed the application following your appointment, you will be notified by email. The application is then available for you to download in encrypted form in the LGP patient portal.
Please upload your approval notice in the LGP patient portal under ("INFO - SUBMIT DOCUMENTS") immediately after you receive it. If you have received a rejection notice from your health insurance fund, you have the option of objecting to the rejection. We are also very happy to support you with this if required. In this case, in addition to your objection, your treating physician must prepare an expert opinion, which you then submit to your health insurance fund. In this case, please upload the rejection notice from your health insurance fund as well as the expert opinion of the MDK to the LGP patient portal.
Legal basis
The statutory requirements that must be fully met in order to obtain the assumption of costs from a statutory health insurance fund following an application are set out in the Fifth Book of the Social Code - Section 31 (6) SGB V.
Insured persons with a serious illness are entitled to be provided with cannabis in the form of dried flowers or extracts of standardised quality and to be provided with medicines containing the active substances dronabinol or nabilone if:
a generally recognised service corresponding to the medical standard
there is a prospect, not entirely remote, of a noticeable positive effect on the course of the illness or on serious symptoms.
Interpretation
An illness is classified as serious if it is life-threatening or if it permanently and substantially impairs the patient's quality of life. The decisive factor here is the extent to which the symptoms or limitations caused by the illness influence the patient's life negatively. In this context, an analysis is made of which consequential impairments to various areas of the patient's life (mobility, work, social contacts, etc.) have resulted from the illness or are still to be expected in the future.
The reasoning of the applying physician must take all relevant aspects into account in detail. In this context, it is helpful if you also explain to the health insurance fund from your own perspective how the illness affects you in various areas of life. These statements can be very detailed and extensive - possibly backed up with a few examples. They should be enclosed with the application for the assumption of costs.
Interpretation
This cannot be answered validly in such general terms. It depends entirely on the underlying illness and your individual situation. For the therapy of illnesses, for example, physicians draw on the guidelines of professional medical societies, in which the sequence and types of therapy for a particular illness (e.g. certain medicines) are described in detail. However, guidelines are not binding and represent only one aspect of the therapy. Rather, your physician must also examine which medicinal or non-medicinal forms of therapy other than cannabis are available with regard to your individual situation, discuss these with you in the interest of medical due diligence and apply them. If, for example, certain medicines cannot be used in your case because of undesirable side effects, this must be extensively documented and assessed and justified in writing by your physician.
The standard therapy does not therefore necessarily arise from an existing guideline. Rather, the state of medical knowledge is characterised by the entirety of all internationally accessible studies. The medicinal and/or non-medicinal alternatives must be available to the insured person under benefits law. According to established BSG case law, a standard therapy is not available if it generally does not exist, if it is ruled out in the specific individual case because the insured person does not tolerate it or there are considerable health risks, or if it has remained without success.
In a landmark ruling of 10 November 2022 (B 1 KR 28/21 R), the Federal Social Court (BSG) set a high standard for the reasoned assessment of the treating physician. As a result, ALL standard therapies must either have been tried or, according to the reasoned assessment of the physician, cannot be applied. This means a considerable amount of work for the applying physician.
Requirements
The decisive point in time for submitting further arguments is the last oral hearing at the trial court of fact, i.e. the Higher Social Court.
What you contribute
In order to submit the application, your physician must answer an extensive catalogue of questions. In addition to this catalogue of questions, all medical documents relevant to the application must be enclosed with the application as an attachment and as evidence. It is therefore necessary that you request all medical documents relating to your previous therapy, such as: physicians' letters, findings, discharge letters from an inpatient hospital stay or a rehabilitation measure, documents on examinations carried out, laboratory findings, etc., and make these available to us in good quality. The therapy with medication carried out so far must also be evident from your documents. If you have undergone further non-medicinal therapy procedures (e.g. physiotherapy, occupational therapy, psychotherapy, acupuncture, etc.), please also send us all evidence of these. The more comprehensibly the previous therapy can be documented, the better your treating physician will be able to set out their reasoned assessment with regard to the desired assumption of costs.
Before prescribing cannabis in the form of dried flowers or extracts, the Medicines Directive requires an examination of whether other finished medicines containing cannabis are available that are suitable for the treatment.
Insofar as extracts are authorised as finished medicines, this means that the fact of the regulatory examination of the quality, efficacy and safety of the medicines must be included in the weighing-up decision on the selection of the cannabis medicine to be prescribed, whereas other cannabis medicines do not have such authorisation. If, when prescribing flowers or extracts, no reasoned assessment is made according to the criteria named as for the standard therapy, the application is incomplete and the socio-medical criteria are not met.
Prescribing cannabis in flower form therefore requires special and reasoned argumentation by the applying physician with regard to the individual particularities of the respective patient.
Deadlines
Patients in specialised outpatient palliative care (SAPV): no application required any longer
Patients in general outpatient palliative care (AAPV): 3 days after receipt of the application
In the case of a prescription immediately following treatment with cannabis medicines during an inpatient hospital stay: 3 days after receipt of the application
For all other patients without involvement of the Medical Service of the Health Insurance Funds (MDK): 2 weeks after receipt of the application
For all other patients with involvement of the Medical Service of the Health Insurance Funds (MDK): 4 weeks after receipt of the application
If you have any questions, you are welcome at any time!