When does the health insurance pay for cosmetic surgery?

Persons with health insurance in Germany, whether statutory or private, are entitled to health treatment under Article 27(1) of the Fifth Book of the Social Code (SGB) if it is necessary to recognise or cure an illness, to prevent it from getting worse or to alleviate symptoms of illness. The legislator sets the following requirements for this:

  1. There must be a disease.
  2. The treatment must be medically necessary.
  3. The treatment must be suitable to bring about relief.
  4. The treatment must have a demonstrable benefit.
  5. The treatment must have a favourable risk-benefit balance.
  6. The treatment must have a better cost-benefit ratio than other equivalent treatments.
  7. The cost-benefit ratio of the treatment must be reasonable for all insured persons.

As a rule, cosmetic surgery must be paid for by patients themselves, as there is no medical necessity.

How do I apply for reimbursement by the health insurance company?

In principle, the application must be made by the insured person himself or herself. An application must be made to the health insurance company for the costs to be covered before the service is used. Entitlement to reimbursement of the cost of an operation shall cease if the application is not made. Your individual findings will determine whether the health insurance company will cover the costs of the treatment. This is decided by the Medical Service of the Health Insurance (MDK) after commissioning by the health insurance.

What deadlines must be observed?

The health insurance company must decide on an application for benefits within three weeks of receipt of the application. If the Medical Service of the health insurance company has been commissioned to examine the application, the deadline is five weeks. Cost absorption will be rejected if the treatment contract is concluded before the expiry of the health insurance company’s decision period for cost absorption. If there is no notification of a sufficient reason, the service is considered approved after the deadline has expired.

Cost absorption rejected – what to do?

If you do not agree with the decision, you can lodge an appeal in writing within one month. If the decision is negative, you can take legal action and file a complaint with the Social Court. We recommend that you weigh up these steps thoroughly with your legal protection insurance and a lawyer specializing in medical law. In the course of the procedure it is usually necessary to clarify a) whether a “disfigurement worthy of illness” in the sense of previous judgements is present (BSG, 10.02.1993 – 1 RK 14/92, 20.06.2005 – B 1 KR 28/04 B, 28.02.2008 – B 1 KR 19/07 R), whether b) the treatment is medically necessary and c) whether the treatment method is recognized by the Joint Federal Committee (G-BA).

What the health insurance companies recognize as a disease

In the opinion of the Federal Social Court, the health insurance companies are obliged to provide benefits if the physical abnormality is significantly pronounced or disfiguring. In other words, the feature “in passing” must “constantly attract many glances” and “not be covered by normal ready-made clothing”. In the following cases, it is highly probable that a cost sharing is to be assumed:

  • Pronounced aprons of fat after massive weight loss with skin inflammations, restrictions in mobility or independent personal hygiene.
  • Excessively large breasts of considerable size with stubborn skin eczema in the breast folds, painful bra lacerations in the shoulder area or posture-related spinal damage
  • Disfiguring protruding ears in children, if there is a considerable impairment of the quality of life due to teasing
  • Eyelid correction for visual field defects.

When is treatment medically necessary?

Treatment is necessary when there is a disease that can be effectively treated. The health disorder to be treated must be sufficiently serious or even threatening. A long history of suffering is evidenced by reports of visits to the doctor to determine and treat the complaints. As proof of this, you can use your list of previous illnesses in which the examination findings and the treatment attempts of your doctors (for example dermatologist, orthopedist, gynecologist) of the last few years are documented.

Which treatments are paid for by the health insurance?

The health insurance company only pays for a treatment if, among other things, the economic efficiency of the treatment has been ensured by the Joint Federal Committee (G-BA) in accordance with § 106 of the German Social Code Book V. Only then is the medical service included in the Uniform Assessment Scale for Contract Physician Services (EBM-Ä) and thus paid.

After breast cancer surgery, for example, retracted and fused scars can remain. The indication of autologous fat injection for the treatment of such scars is defined in a guideline of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. (AWMF). The AWMF develops fact-based and interdisciplinary guidelines. Nevertheless, breast reconstruction after breast cancer surgery using autologous fat injections is not recommended by the Federal Joint Committee (G-BA). For this reason, own-fat treatment is not covered by health insurance (Hessisches LSG, 31.10.2014 – L 1 KR 197/14).

The recommendation of the G-BA was often limited and many years after scientific studies on the benefits of the treatments were published. Examples include liposuction for lipedema and the outpatient vacuum treatment of wounds.

What does a refusal of cost coverage mean?

If the health insurance refuses to cover the costs, the following consequences must be expected:

  • The costs of the treatment will not be covered.
  • Plastic surgery that is not medically indicated is subject to sales tax.
  • The costs of any complications that may require treatment and that may result from a treatment are not covered (§ 52 para. 2 SGB V). We therefore recommend follow-up cost insurance in the event of an operation.
  • A certificate of incapacity for work may not be issued.
  • Prescriptions for drugs or remedies must not be at the expense of the health insurance.

Where can I get a certificate for cost coverage?

Please note that if the costs are covered by the health insurance, the aim of the treatment is to alleviate an illness. Justified aesthetic claims are not in the foreground when the costs are covered by the health insurance. Health insurance benefits must not exceed what is medically necessary (SGB V, § 12). Also, the assumption of costs by health insurance companies is usually accompanied by inpatient treatment.

Where can I get a certificate to cover the costs?

A certificate is a written expert opinion from the objective point of view of the independent expert. With the issuing of an expert opinion comes a high level of responsibility. Issuing incorrect health certificates against one’s better knowledge is a violation of the professional code of conduct and a violation of the Criminal Code (StGB, § 278). Furthermore, the issuance of inaccurate certificates is unethical in the extreme.

The application for reimbursement is initiated with a specialist’s written opinion after careful examination and photographic documentation. In the opinion, objective medical findings are collected, without taking into account the subjective feelings of the expert. On the basis of his expertise and experience, the question of necessity must be justified in a comprehensible manner. The expert opinion must stand up to scrutiny by the Medical Service of the Health Insurance Fund. Since there are already many court decisions on the question of the assumption of costs by the health insurance company, the MDK reviews the expert opinion according to the standards of precedents.

The detailed examination, the comprehensive medical photo documentation and the written statement with scientific justification are charged according to the German Medical Fee Schedule (GOÄ). The fee amounts to approx. A private appraisal shall be conducted in accordance with sec. 85 GOÄ 6-fold rate (€ 174.86 per hour) plus VAT and typing fees. The time required to prepare an expert opinion depends on the issue and is at least 6 hours.

Author’s statement

Author: Stéphane Stahl, MD, PhD. There are no financial relationships with the pharmaceutical or medical device industries that could have influenced the above text. Any reproduction, even partial, is permitted for personal use only. All texts used on this website are protected by copyright.

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