Méningiomes and Androcur- CNAM- Health insurance- October 24, 2019
The association had an appointment on October 24 at the National Health Insurance Fund in order to be able to have information on ALD and to raise the dysfunctions on which members of the association alerted us.
ALD
The long -term affection management (ALD) is governed by the Social Security Code (CSS). Until recently the list of diseases that made it possible to benefit from ALD (article D322-1du CSS) included 30 conditions (diabetes, cancerous tumor, heart failure ...) This is why we were talking about the list of " ALD 30". This list is the subject of updates, and it only has only 29 conditions, but we continue to talk about the list of " ALD 30 ". The CSS offers another possibility of 100% management: this is the “ out-list ” diet (article L322-3 of the CSS) also called “ ALD 31” . This possibility concerns patients with characterized serious condition, not on the ALD 30 list and which requires prolonged and expensive treatment. These criteria were specified in a ministerial circular accessible with this link:
It is on these criteria that doctors of health insurance advice are based to give, everywhere on the national territory, their opinion on the requests made by the insured.
As meningioma is not on the list of ALD 30s, it is on the basis of ALD 31 that a insured person reaches this condition can be admitted to ALD: it is necessary that his illness fulfills the criteria above. In other words, all meningiomas are not automatically admitted to ALD 31, it all depends on their location (s), their size (s), and the treatment implemented.
It is necessary to emphasize that the affections which are entitled to ALD 31 are in no way considered by health insurance as less important than those on the ALD 30 list: ALD 31 allows you to take care of serious situations or pathologies which are not included in ALD 30.
When a attending physician requests the ALD " out of list " for a patient with a meningioma , he must argue this request so that the doctor counsel can give an opinion in accordance with the regulations. The objective of health insurance is the national consistency of the opinions rendered by the advice doctors. However, there are complex cases where exchanges between the attending physician and the advice doctor are desirable. In the event that the association learns that difficulties are repeated in a given region, it could then inform the CNAM.
Health transport
The CNAM recalled that transport costs are not necessarily covered when there is ALD, and in contrast , that they can be taken care of without there is an ALD. These conditions are described in the decree of December 23, 2006, with decree of March 10, 2011. We will find on this link a very well done summary
https://www.ameli.fr/sites/default/files/documents/345733/document/memo_prescription_transports.pdf
Severe hirsutism
What management of severe hirsutism, when Androcur® (Cyproterone acetate) can no longer be prescribed?
A CNAM epility: Health insurance takes care, without request for a prior agreement, hair removal sessions with laser or flash lamp. Management is subject to the commitment of the doctor to respect the indication (in this case pathological hypertrichosis, confirmed and documented hirsutism ). The doctor translates this commitment by checking the RC box, and it is essential for reimbursement. The code to be used by the doctor is QZNP028, QZNP 029 or QZNP030 as a function of the surface treated with reimbursement bases ranging from 17.8 euros to 43.43 euros,
RADIOTHERAPY
Radiation therapy in day hospital. What about accommodation costs when the person comes from far away and cannot pay them?
Response from the CNAM: People who encounter this type of difficulty can apply for financial assistance from their primary fund, which studies these requests within a health and social action committee. These aids are subject to resource conditions.
ANSM-ASSURANCE MANEY
All women who have taken Androcur® in the last 24 months have not received the ANSM alert mail and health insurance. For what ?
CNAM response: A letter has been sent to all the women concerned with the general health insurance plan. The other regimes (MSA, RATP, SBNCF, MGEN, etc.) were informed of the procedure to follow, but we have no information on what was done at their level.
We thank the doctors- CNAM advice for listening and their answers.
Report validated by the CNAM, represented by Dr Geneviève Motyka
The report is here: CNAM_24102019
We thank Doctor Geneviève Mcyka for her listening and his availability.
If you encounter difficulties with your primary health insurance fund (CPAM), you can tell us about it and we will try to find solutions.
Méningiomes and Androcur- CNAM- Health insurance- October 24, 2019
Health insurance site here
