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Reimbursement summary for angioplasty of arteries of lower extremities

This post presents an extract from our reimbursement analysis for angioplasty of arteries lower extremities using plain and drug-coated balloons (DCBs) for peripheral artery disease in England, France and Germany. Plain balloon angioplasty is reimbursement via DRG solely and DCBs are reimbursement via combination of DRG and add-on reimbursement.
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Three medical procedures covered with evidence development in Switzerland

According to the principle of trust, medical services including devices and in-vivo diagnostics are covered by Swiss statutory health insurance (SHI) scheme without formal health technology assessments (HTA). However, in case of doubt that a medical service is effective, appropriate and efficient, it can be reported to the Federal Office of Public Health (FOPH) who reviews the available evidence on effectiveness, appropriateness, and cost-effectiveness of the method. The Department of Home Affairs (EDI) takes the final decision about the coverage of the service in the form of one of three possible outcomes:

•          Yes – continued coverage

•          No – exclusion from coverage

•          Yes, in evaluation – coverage while further evidence is collected

The status “Yes, in evaluation” can be connected to conditions as to lead a patient-based register or that reimbursement is limited to specific indications, centers or medical specialists. The status is set for a specific period which is extended until evidence is complete and can be considered as coverage with evidence development (CED) scheme.

On January 1st of 2018, this status was given to following medical services:

  • Positron emission tomography (PET, PET / CT) in the question "Massaging", according to the clinical guidelines of the SGNM, chapter 2.0, dated April 28, 2011 on FDG-PET. Status valid until 31.12.2018
  • Positron emission tomography (PET, PET / CT) using 18F-fluorocholine to clarify biochemically proven recurrence (PSA increase) of a prostate carcinoma. Status valid until 31.12.2018
  • Ambulatory stereotactic radiotherapy (photons) of exudative age-related macular degeneration if conditions below are met. Status valid until 30.6.2020
    • Choroidal neovascularization (CNV) with signs of activity such as intraretinal fluid or hemorrhage
    • Ongoing anti-VEGF therapy over a period of at least six months and thus exclusion of an under-treatment
    • No change in CNV activity status despite intensive injection therapy and no expected decline in the need for a high frequency of treatment in the future
    • Diameter of CNV maximal 4 mm (center maximally 3 mm away from the fovea)

The first two services (positron emission tomography) were given the CED-status previously and it was now renewed until the end of the year. Stereotactic radiotherapy is under CED for the first time in Switzerland.

Decisions by the Department of Home Affairs (EDI) about the coverage of medical services are documented in Annex 1 of the health care benefit ordinance (KLV).

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