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Big dispute over therapy sovereignty with cannabis


LSG Mainz and SG Düsseldorf specify different lines
Since cannabis has been prescribed as a medicine under certain conditions at the expense of statutory health insurance since March 2017, the courts are now also arguing about this with patients, doctors and health insurers. According to an emergency decision of the Social Court (SG) Düsseldorf published on August 24, 2017, cannabis can only be prescribed as a proven last resort at the expense of statutory health insurance (file number: S 27 KR 698/17 ER). In contrast, the State Social Court (LSG) Rhineland-Palatinate in Mainz, in a decision published on August 22, 2017, gives doctors significantly more freedom of therapy (file number: L 5 KR 140/17 B ER).

As of March 10, 2017, a new regulation was introduced into the Social Code, which enables the regulation of cannabis at the expense of the statutory health insurance funds. The prerequisite is that this promises at least relief for a "serious illness". In addition, there must be no conventional medical alternatives or these should not be reasonable for the patient in the opinion of the doctor, for example due to severe side effects. The health fund may then reject an appropriately justified application "only in justified exceptional cases".

In the Düsseldorf case, the patient suffers from polyarthritis (inflammatory pain at various joints) and ankylosing spondylitis (inflammatory and progressive stiffening and curvature of the spine).

The now 67-year-old and severely disabled man has been treated with cannabis since 2008. Before that, standard therapy had had serious side effects. Since the cannabis therapy, he has not had any flare-ups, pain and side effects have decreased significantly.

However, the man could not or did not want to bear the costs of a good 1,000 euros per month. Exactly on March 10, 2017, he submitted an application for reimbursement to his health insurance company.

The SG Düsseldorf was right to refuse this. Although there is a serious illness, alternative therapies are available. His last standard therapy was 16 years ago. In view of medical progress, it cannot be assumed that even newer therapy options - for example with drugs that suppress the immune system - have unacceptable side effects for him, according to the SG in its decision of August 8, 2017.

While the SG Düsseldorf imposes very high justification obligations on doctors and patients, the LSG Mainz gives them significantly more freedom of choice and therapy.

Here the 34-year-old plaintiff suffers from psoriasis arthropathy, which is associated with painful changes in the joints. According to the doctor, the disease now affects almost all joints and leads to a "morning stiffness" of 60 minutes. The results of other treatments have so far remained unsatisfactory.

Here, too, the health insurance company declined. The doctor had not ruled out numerous alternative treatment options for good reason.

Nevertheless, in this case - like the SG Koblenz before - the LSG Mainz agreed with the patient on July 27, 2017. His doctor had endorsed the treatment and clearly stated that pain relief was the goal. According to the law, the health insurance funds should only reject such an application in exceptional cases. Here the doctor also has an addiction medical qualification, so that "his professional advocacy" is particularly important. According to credible statements by the employer, the patient is suffering from severe pain without cannabis and is unable to work.

Both the Düsseldorf and the Mainz decision were made in an urgent procedure. They are therefore only valid until a final judgment in the skin matter. mwo / fle

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