Coverage of treatment costs by statutory health insurance for a Botox treatment?
Coverage of treatment costs by statutory health insurance for botulinum toxin (Botox)?
For aesthetic indications (e.g. the treatment of glabellar lines), botulinum toxin is not a benefit covered by statutory health insurance. However, where so-called therapeutic indications are concerned, i.e. medical purposes that are also mentioned in the summary of product characteristics of the botulinum toxin product, the treatment can be billed to statutory health insurance (GKV).
The following indications are covered:
Neurological disorders
- Focal spasticity associated with dynamic equinus foot deformity due to spasticity in ambulant patients with infantile cerebral palsy who are two years of age or older
- Focal spasticity of the wrist and hand in adult stroke patients
- Focal spasticity of the ankle in adult stroke patients
- Blepharospasm, hemifacial spasm and coexisting focal dystonias
- Cervical dystonia (spasmodic torticollis)
- Relief of symptoms in adult patients who meet the criteria for chronic migraine. That is, headaches on more than 15 days per month, of which at least eight days with migraine, and inadequate response or intolerance to prophylactic migraine medication.
Bladder dysfunction
- Idiopathic overactive bladder with the symptoms
- Urinary incontinence, urinary urgency and urinary frequency in adult patients who have responded only inadequately to anticholinergics or have not tolerated them. Urinary incontinence in adults with neurogenic detrusor overactivity in neurogenic bladder due to a stable subcervical spinal cord injury or multiple sclerosis.
Disorders of the skin and skin-related disorders
- Severe, persistent primary axillary hyperhidrosis that interferes with the activities of daily living and cannot be adequately controlled with topical treatment.
When the product is dispensed in the pharmacy, there is currently no obligation to check whether one of the conditions mentioned is present. If a product is used without authorisation for an indication (i.e. one not listed in the summary of product characteristics) or if clinical conditions other than those mentioned above are concerned, it is always advisable to consult the respective health insurance fund before treatment. Here, reimbursement depends heavily on the individual case and often requires a review by the Medical Service of the Health Insurance Funds (MDK).
Source:
Was ist bei der Abgabe von Botox zu beachten? DAZ.online. Mai 2021