Facts
[A.], born in 1942, is mandatorily insured for medical care with Sanitas Grundversicherungen AG. Since 2007, he has been suffering from recurrent multiple myeloma. In an application dated December 14, 2017, his attending physician, Prof. Dr. med. B., requested Sanitas to approve the costs for A.'s treatment using a combination therapy with Darzalex/Revlimid/Dexamethasone. The health insurer rejected the service, whereupon [A.] filed an objection. The Social Insurance Court of the Canton of Zurich upheld the complaint and obliged Sanitas to cover the costs of the combination therapy.
The Federal Office of Public Health (FOPH) appeals in public law matters and requests that the lower court's decision be overturned and Sanitas' objection decision be confirmed.
Considerations
The Federal Supreme Court examines whether the lower court violated federal law by obliging Sanitas to cover the costs of the respondent's treatment with the combination therapy Darzalex/Revlimid/Dexamethasone.
The Federal Supreme Court states that the mandatory health insurance (OKP) generally only covers the medicinal products listed in the Pharmaceutical List (ALT) and the Specialty List (SL). An exception may exist under Art. 71a para. 1 lit. b KVV if the use of the medicinal product is expected to provide a significant therapeutic benefit against a disease that can be fatal or lead to severe and chronic health impairments for the insured person, and no effective and approved treatment method is available due to a lack of therapeutic alternatives.
The Federal Supreme Court considers it to be fulfilled that there is no effective treatment alternative to the requested combination therapy for the respondent and that this promises a high therapeutic benefit. However, the lower court did not sufficiently examine the cost-effectiveness of the combination therapy. According to Art.…