Rejection of Cost Coverage for Treatment with the Medication Myozyme for Pompe Disease

Facts

F., born in 1940, is mandatorily health insured with Publisana. In mid-2007, she was diagnosed with Pompe disease. In October 2007, Publisana granted cost approval for a six-month treatment with the medication Myozyme. After the expiration of this treatment, Publisana rejected the cost coverage for a continuation of the therapy in a decision dated 22 October 2008 and an objection decision dated 18 March 2009. The Insurance Court of the Canton of Aargau subsequently obliged Publisana to cover the costs of the treatment for a period of two years. Publisana then filed a complaint with the Federal Supreme Court.

Considerations

The Federal Supreme Court first examined whether there is a high therapeutic benefit of the treatment with Myozyme that would justify an exception to the obligation to include it in the specialty list. It concluded that while a certain therapeutic benefit can be assumed, it does not reach the required high degree. Even if a high therapeutic benefit were proven, the obligation to…