New coverage decisions for procedures and tests in Switzerland (KLV/OPre)

The Federal Department of Home Affairs (FDHA) has decided on 30 November 2018 to introduce several changes to the list of covered benefits (KLV/OPre) outlined its annexes 1 (list of defined services provided by physicians), 1a (restriction of cost assumption for specific interventions), 2 (list of medical aids) and 3 (list of laboratory analyses). The amendments came into effect on January 1, 2019.

These changes were presented in the magazine of the Federal Office for Public Health - “Bulletin” (page 12), which was published on January 7, 2019.

Annex 1 (physician services) changes:

• Coverage of Transcatheter Aortic Valve Implantation (TAVI) under specific conditions is extended until June 30, 2019
• Coverage of Multigenic Expression Test for breast cancer under particular conditions is extended until December 31, 2023
• Sub-urethral tapes for the treatment of stress urinary incontinence in women is covered, as of January 1, 2019 (after adopting the experts’ opinion "Setting up tapes for the treatment of female stress urinary incontinence" of June 2016)
• Coverage of positron emission tomography (PET, PET / CT) using FDG for diagnostic purposes of the "mass effect," under evaluation conditions, is extended until December 31, 2019. Furthermore, diagnostic PET / CT examination of a proven biochemical recurrence of prostatic carcinoma became a mandatory benefit (applies to both fluorocholine and PSMA tracer analyses)
• Coverage of local superficial hyperthermia during tumour treatment, combined with external radiotherapy or brachytherapy, is extended until 31 December 2020 (under specific conditions)

 Annex 1a (restriction of cost assumption for certain interventions) changes:

• For six intervention groups (found in section I of annex 1a of KLV/OPre), the costs of are covered by the Mandatory Health Insurance (MHI) only if performed in an outpatient setting (except for certain special conditions). Specific conditions that may warrant inpatient intervention are described in section II 2 of annex 1a. If an intervention is to be performed in inpatient settings for other reasons, it is necessary to submit a request for the coverage of the costs to the insurer in advance

Annex 2 (medical aids and equipment) changes:

• Coverage of the rental of the vest with defibrillator (position 09.03.01.00.2 (Portable Defibrillator (Wearable Cardioverter Defibrillator, WCD; 09.03))) under specific conditions is extended until 31 December 2021

Annex 3 (laboratory analyses) changes:

• Neonatal screening (position 1368.00) includes screening for severe congenital immunodeficiencies (IDCS), as of January 1, 2019. The extension of newborn screening to IDCS is limited to five years and must be re-evaluated after this period. Furthermore, there is an increase of the 1368.00 tariff from 45.5 to 54 tariff points
• Neonatal screening for cystic fibrosis (position 1368.00) is covered without conditions, as of January 1, 2019

The downloadable document (number one of 2019 “Bulletin”) can be found in French (change to another language in the top-right corner) here. Furthermore, see the whole 2019 version of KLV/OPre (choose the preferred language in the top-right corner) here.

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