Impending blindness is an emergency-like situation

A recent court ruling by the Regional Social Court of Lower Saxony-Bremen (LSG) paves the way for the retroactive reimbursement of OkuStim® therapy for Retinitis pigmentosa (RP). A patient had filed a lawsuit because her health insurance company refused to cover the costs, arguing that impending blindness was not to be expected and that the therapeutic benefit of TES had not yet been evaluated by the Federal Joint Committee (G-BA).

The LSG bases its decision on the unquantifiable specific prognosis period for Retinitis pigmentosa (RP). Accordingly, the irreversible loss of residual vision and impending blindness constitute an emergency-like situation, even if the time at which the irreparable damage occurs is not predictable. The disease had reached a stage in the plaintiff, with a visual field constriction to 10 degrees, where further waiting would no longer be reasonable. Transcorneal electrical stimulation (TES) with the OkuStim® system would no longer have any medical benefit for the plaintiff at a later stage. The plaintiff’s health insurance company must now reimburse the costs for the acquisition of the OkuStim® system and cover her future therapy costs.

In December 2017, the plaintiff unsuccessfully applied to her health insurance company for coverage of the costs for OkuStim® therapy. At that time, she still had a visual field of 10 degrees and a visual acuity of 0.8. Meanwhile, the plaintiff had started OkuStim® therapy at her own expense. Following a medical opinion, the Regional Social Court stated in its judgment that a noticeable positive effect of TES on the course of the disease had already occurred.

OkuStim® therapy can slow down the progressive loss of the visual field in Retinitis pigmentosa. A current trial study, commissioned by the G-BA, is investigating the effectiveness and long-term benefits of the therapy. Only with a positive benefit assessment can regular coverage of therapy costs by health insurance companies take place. For self-payers, the CE-marked OkuStim® system is available through clinical competence centers in several European countries.