Health care medicine ordinance

Ordinance governing the principles for the medical assessment of the consequences of damage and the determination of the degree of damage within the meaning of Section 30(1) of the Federal Care Act for:

• the recognition of a health disorder according to § 1 para. 3 of the Federal Supply Act
• the criteria for assessing helplessness and the levels of the long-term care allowance under Section 35(1) of the Federal Care Act
• the procedure for determining and further developing them

The principles and criteria mentioned here (relevant to dermatology) are laid down in the Annex to this Regulation as an integral part thereof.

Part C: Assessment in social compensation law

1. concept of cause

a) The concept of cause under health care law is not identical with that of medicine.

b) Cause in the sense of the Versorgungsgesetze is the condition in the scientific-philosophical sense which, because of its special relationship to success, has played a significant role in its occurrence. If several circumstances have contributed to a success, they are only considered to be co-causes (and causes) under the law on pensions if they are approximately equivalent in their significance and scope for the occurrence of the success. If one of the circumstances is of overriding importance compared with the other, this circumstance alone is a cause within the meaning of pension law.

c) Injury to health is the primary impairment of health as a result of the damaging process, such as wounding, injury through accident, reduction of resistance through stress. The remaining impairment of health is the damage sequence (military service damage sequence [WDB sequence], civil service damage sequence [ZDB sequence], etc.).

3. probability of the causal connection

a) For the assumption that a health disorder is the result of an injury, the probability of the causal link is sufficient in terms of supply law. This is given if, according to the current medical-scientific doctrine, there is more evidence for a causal connection than against it. The pros and cons must be weighed up with particular care. Even in the case of difficult questions of context, efforts should be made to arrive at a usable assessment in the expert opinion.

b) The basis for the medical evaluation is the knowledge of etiology and pathogenesis represented by the prevailing scientific opinion. It is not sufficient that a single scientist has made a working hypothesis or attempted to explain it. Nor does the subjective opinion of the person making the judgement alone make a difference.

c) In many cases, the long time interval without bridging symptoms alone makes the causal relationship appear improbable. The appropriate temporal connection is usually a prerequisite for the probability of the causal connection. On the other hand, the time link between a health disorder and the service provided cannot in itself establish the probability of causality. The fact that, for example, a soldier was healthy on entering service, that he was exposed to the influences of service and that an illness arose or emerged during the period of service is not sufficient for the assumption of a causal link. Rather, the unfavourable influence of a particular performance of duty or general conditions of service on the development or aggravation of the illness must be demonstrated, since illnesses of all kinds, in particular internal ailments, can arise at any time even without any significant contribution to a damaging process.

d) It cannot be concluded from the fact that the connection of the health disorder with a damaging process cannot be excluded according to scientific knowledge that it is therefore probable. Nor can the existence of a damaging consequence be affirmed if a causal connection is only possible.

4. optional care

a) In deviation from the principles explained above, a health disorder can be recognized as a consequence of an injury according to § 1, Subsection 3, Sentence 2 of the Federal Health Care Act (BVG) if the probability required for the recognition of a health disorder as a consequence of an injury is not given only because there is uncertainty in medical science about the cause of the identified illness (optional care). All other laws of social compensation law also contain an identical provision.

6 Intentionally caused injuries

Damage deliberately caused by the injured person is not regarded as damage in the sense of the supply laws. It is deliberately caused if the damaged person intended it. Suicide and the consequences of an attempted suicide or self-harm are not intentionally caused if an impairment of the free will is likely to be caused by supply-protected facts.

7. recognition in the sense of emergence and recognition in the sense of aggravation

a) The recognition of a health disorder in the sense of its origin requires that at the time of the effect of the damaging process no pathological physical or psychological event associated with this health disorder was present. This also applies if a disposition to the health disorder can be inferred. If, at the time of the effect of the damaging process, a pathological physical or psychological event associated with a health disorder already existed, even if it had not yet been noticed, recognition in the sense of aggravation is only possible if the external influence either brought forward the time at which the suffering would otherwise have appeared or the suffering occurred in a more severe form than would otherwise have been expected. The concept of aggravation is to be distinguished from this concept of aggravation in the sense of a substantial change in circumstances.

8. types of aggravation

From a medical point of view, a distinction is made between different types of exacerbation. A damaging process can only temporarily lead to an increase in the value of the disease and thus to none or not to a permanent damage-related GdS; it can have a lasting but definable influence on the further course of the disease and thus lead to a constant damage-related GdS; but it can also determine the further course of the disease and thus be the cause of an increasing damage-related GdS. Frequently, it will only be possible to assess the extent of the influence of the damaging process after a longer period of observation of the course of the disease. The extent of the aggravation is essential for the determination of the GdS. The total GdS caused by the health disorder and the GdS for the proportion of aggravation due to damage consequences and the extent of the previous damage must always be stated. Independent of the medical assessment of the type of aggravation, the causal relationship of this further development must be reassessed each time the value of the disease increases.

9. absence of professional treatment

Health disorders in the course of which harmful effects have not contributed to their occurrence can come into a causal connection with harmful influences if, due to conditions inherent to the service or prison, or the consequences of damage, a professional and probably successful treatment is not carried out or is carried out too late.

13. conditions for the care allowance, care allowance levels

(a) Care allowance shall be granted as long as the injured person is so helpless as a result of the injury that he/she requires constant assistance from others for a number of frequently and regularly recurring tasks to secure his/her personal existence during the course of each day. These conditions are also fulfilled if the assistance is required in the form of supervision or instruction for the aforementioned tasks or if the assistance does not have to be provided on a permanent basis, but a constant readiness to provide assistance is required.

(b) The helplessness must be caused by the consequences of the injury. It is not necessary that it is solely or predominantly due to the consequences of the injury. It is sufficient that for the occurrence of the helplessness - or also for an increase in the need for care - the consequence of the damage has approximately the same significance as other health disorders.

(c) The care allowance shall be granted in six stages. Levels II to VI are provided for permanent sick leave or permanent exceptional care.

(d) A permanent exceptional need for care exists if the amount of care required is approximately the same as for permanent sick-leave of an injured person. Permanent sick-leave does not mean that the person cannot leave the bed at all.

Versorgungsmedizin-Verordnung ( dermatologically relevant excerpt from the ordinance of the Federal Ministry of Justice of March 1, 2010)

General principles: When the degree of disability and the degree of damage are used to measure the extent to which participation in life in the community is impaired, the abbreviation GdS is used.

1. consequences of damage

a) In social compensation law, a consequence of damage is defined as any impairment of health that is causally connected with an injury that must be taken into account under the relevant law.

b) The effects of the damage sequence are measured with the degree of the damage consequences (GdS).

c) The damage consequences also include deviations from the state of health that do not cause GdS (e.g. functionally meaningless scars, loss of teeth).

2. degree of damage consequences (GdS), degree of disability (GdB)

(a) GdS and GdB are measured according to the same principles. The only difference between the two terms is that GdS only refers to the consequences of damage (i.e. causal) and GdB refers to all health disorders regardless of their cause (i.e. final). Both terms refer to the effects of functional impairments in all areas of life and not only to the restrictions in general working life. GdS and GdB are a measure of the physical, mental, emotional and social effects of a

Impairment of function due to damage to health.

b) From the GdB and the GdS it is not possible to infer the extent of the performance capability. GdB and GdS are to be judged in principle independently of the exercised or desired occupation, unless a special occupational affectedness must be taken into account in appraisals in social compensation law.

c) GdB and GdS always presuppose an irregularity in relation to the typical condition of age. This must be taken into account in particular with children and old people. Physiological changes in age are not to be taken into account in the assessment of GdB and GdS. As such changes are to be regarded the physical and psychological performance restrictions which develop regularly in old age, i.e. which are typical for old age according to their type and extent. In contrast, pathological changes, i.e. health disorders that cannot be observed regularly and not only in old age, must be taken into account in the assessment of GdB and GdS, even if they occur for the first time in old age or are referred to as "diseases of old age".

d) The values listed in the GdS table are derived from long experience and represent age-independent (also training-independent) mean values. Depending on the individual case, deviations from the table values may be made with a justification representing the special circumstances.

e) Since the GdS can only be determined approximately by its nature, only tens of values are to be given for the GdS.

(f) The GdS presupposes a health disorder that is not merely temporary and thus extends over a period of more than six months. Accordingly, in the case of diminishing health problems, the value corresponding to the damage remaining - or likely to remain - for more than six months shall be determined. Fluctuations in the state of health in the case of a longer course of suffering are to be taken into account with an average value.

3. total GdS

(a) where there is more than one functional impairment, individual CdS must be reported; however, when calculating the total CdS from all functional impairments, the individual values must not be added together Other calculation methods are also unsuitable for forming a total CdS. The effects of the individual functional impairments in their entirety are decisive, taking into account their interrelationships.

(b) In the overall assessment of the various functional impairments, comparisons shall be made with health impairments for which fixed GdS values are given in the table, taking into account all socio-medical experience.

c) In the assessment of the overall GdS, the functional impairment which causes the highest individual GdS shall normally be taken as the starting point and then, with regard to all other functional impairments, it shall be examined whether and to what extent the extent of the disability is increased as a result, i.e. whether 10 or 20 or more points should be added to the first GdS because of the other functional impairments in order to do justice to the disability as a whole.

d) In order to be able to assess the effects of the functional impairments in their entirety, taking into account their interrelationships with one another, it must be borne in mind from a general medical perspective that the relationships between the functional impairments may be different:

aa) The effects of the individual functional impairments may be independent of each other and thus affect very different areas of daily life.

bb) One functional impairment can have a particularly adverse effect on another. This is particularly the case when there is functional impairment of paired limbs or organs, for example, both arms or both legs, or both kidneys or both eyes.

cc) The effects of functional impairments may overlap.

dd) The effects of a functional impairment are not increased by an additional health disorder.

General notes on the GdS table

a) The GdS relevant to the subject of dermatology below are indicative values. It is indispensable to take into account all physical, mental and emotional disorders impairing participation in the individual case. The assessment ranges take into account the particularities of the individual case.

Simple facial disfigurement (numerical data as degree of disability)

• only slightly disturbing 10

• otherwise 20-30

Severe disfigurement of the face

50

Sensitivity disorders in the facial area

• Light: 0-10

• moderate (more frequent, mild to moderate pain, can be triggered by even slight stimuli): 20-40

• severe ((frequent, severe pain or pain attacks several times a month): 50-60

• particularly severe (severe continuous pain or pain attacks several times a week): 70-80

9) Vascular diseases

Arterial occlusive disease,

• Arterial occlusions in the legs (also after recanalization measures) with sufficient residual blood flow, pulse failure without complaints or with minor complaints (discomfort in calf and foot when walking quickly) on one or both sides: 0-10

• with restricted residual blood flow (intermittent claudication) Stage II pain on one or both sides after walking a distance in the plane of more than 500 m 20

• Pain on one or both sides after walking a distance of 100 to 500 m in the plain: 30-40

• Pain on one or both sides after walking a distance of 50 to 100 m in the plane: 50-60

• Pain on one or both sides after walking a distance of less than 50 m in the plain without pain at rest 70-80

• Pain after walking a distance of less than 50 m with pain at rest (stage III) including trophic disorders (stage IV)

  • one-sided 80

  • on both sides 90-100

• Note: In the case of arterial occlusion in the arms, GdS is also determined by the extent of the complaints and functional limitations - compared with other damage to the arms.

• After major vascular surgery (e.g. prosthesis implantation) with full compensation including permanent treatment with anticoagulants 20

9.2.3 Uncomplicated varicose veins

• Chronic venous insufficiency (e.g. in varicose veins), postthrombotic syndrome on one or both sides with slight load-dependent oedema, non-ulcerous skin changes, without significant congestion problems 0-10

• with considerable edema formation, frequently (several times a year) recurrent inflammations 20-30

• with chronic recurrent ulcers, depending on their extent and frequency (including arthrogenous stasis syndrome) 30-50

9.3 Lymphedema

• along a limb

• without significant functional impairment, requires a compression bandage 0-10

• with stronger circumferential increase (more than 3 cm) depending on the functional limitation 20-40

• with considerable impairment of the usability of the affected limb, depending on the extent 50-70

• in case of inability to use the whole limb 80

• Remark: Disfigurement of very pronounced shapes may need to be considered additionally.

16.3 Non-Hodgkin lymphomas

• 16.3.1 Chronic lymphocytic leukaemia and other generalized low-grade non-Hodgkin's lymphomas with minor effects (no major complaints, no general symptoms, no need for treatment, no significant progression) 30-40

• with moderate effects (need for treatment) 50-70

• with severe effects, severe progression (e.g. severe anaemia, pronounced thrombocytopenia, recurrent infections, severe splenomegaly) 80-100

Localized low-malignant non-Hodgkin lymphomas after full remission (elimination of the tumor) for a period of three years (proof of cure) 50

16.3.2 Highly malignant non-Hodgkin lymphomas

• by the end of intensive therapy 100

• after full remission GdS for a period of three years (healing probation) 80

16.6 Acute leukaemias, myelodysplastic syndromes (to be treated as internal medicine issues)

Acquired immune deficiency syndrome (HIV infection)

• HIV infection without clinical symptoms 10

• HIV infection with clinical symptoms slight impairment of performance (e.g. lymphadenopathy syndrome [LAS]) 30-40

• greater impairment of performance (e.g. in AIDS-related complex [ARC]) 50-80)

• severe impairment of performance (AIDS full picture) 100

17. skin

When assessing the GdS of skin diseases, the type, extent, location, effects on the general condition, accompanying symptoms (such as itching, weeping, burning, unpleasant and repulsive odours) and the readiness for recurrence or chronicity as well as the necessity of repeated inpatient treatment must be taken into account. In the case of skin diseases with a strongly fluctuating course of suffering, an average GdS is considered. Skin diseases can have a more severe impact on children than on adults. Scars may be disrupted by expansion, texture (e.g. hardening, thinning, scar tissue), fit or exposure to their surroundings. In the case of extensive scars after burns, chemical burns and the like, the impairment of the skin as a protective, excretory and sensory organ must also be taken into account. These disturbances determine the level of GdS. In the case of disfigurement, it must be taken into account that difficulties in working life, inconvenience in intercourse with strangers and mental conflicts may arise.

17.1 Eczema

• Contact eczema (e.g. irritant and allergic contact eczema) small extent and occurring up to twice a year for a few weeks 0-10
• Otherwise 20-30

Atopic eczema (syn.: atopic dermatitis, endogenous eczema")

• small extension limited to the predilection sites up to twice a year for a few weeks 0-10

• in case of longer lasting existence 20-30

• with generalized skin symptoms, especially facial infestation 40

• with clinical or comparable intensive outpatient treatment need several times a year 50

seborrheic eczema

• small extension and limitation to the predilection sites 0-10
• otherwise depending on expansion 20-30

17.2 Chronic recurrent urticaria/quincke's edema

• rarely, up to 2x per year, easily avoidable noxae or allergens 0-10
• more frequent relapses, hard-to-prevent noxae or allergens 20-30
• severe chronic, protracted course over years 40-50
• A systemic involvement, e.g. of the gastrointestinal tract or the circulatory system, must also be taken into account if necessary (additional gastroenterological opinion).

17.3 Acne

acne vulgaris

• Light to medium grade 0-10
• of severe degree with isolated abscesses and nodules and corresponding significant cosmetic impairment 20-30

acne conglobata

• frequent abscess and fistula formation limited to the predilection sites and
• localisation-related impairments 30-40
• Most severe forms with recurrent purulent, scarring axillary linguinal and nuchal abscesses (acne triad) and possibly additional involvement of the pilonidal sinus (acne tetrade) at least 50

17.4 Rosacea, Rhinophyma

• low expansion, only slightly disturbing cosmetically 0-10

• greater expansion, disfiguring effect 20-30

17.5 Skin changes in autoimmune diseases of the connective tissue (e.g. lupus erythematosus, dermatomyositis, progressive systemic scleroderma)

• limited to the predilection sites with small extension 0-10
• limited to the predilection sites with a greater extension, depending on the cosmetic and functional effect 20-40
• beyond the predilection sites, ulcerations 50-70

17.6 Blistering skin diseases (e.g. pemphigus, pemphigoids)

• for limited skin and mucous membrane infestation with low expansion 10
• otherwise 20-40
• for generalized skin and mucous membrane infestation 50-80 in advanced stages with severe impairment of the general condition also higher.

17.7 Psoriasis vulgaris

• restricted to the predilection sites 0-10

• extended, but non-appearing intervals of months, 20

• in case of persistent extensive infestation or strongly impairing local infestation (e.g. on the hands) 30-50

• Exceptional nail involvement (with destruction of the nail plates) as well as joint and spinal involvement must be evaluated additionally.

17.8 Erythroderma

• for mild intensity of the disease process 40

• at medium intensity of the disease process without significant effect on the general condition 50-60

• with a stronger impact on the general condition 70-80

17.9 Ichthyosis

• slight shape, largely limited to the trunk and extremities, with dry skin, moderate scaling, no significant discoloration 0-10

• medium form largely limited to trunk and extremities, with more pronounced scaling and discoloration 20-40

• severe form with pronounced scaling and discoloration of the entire skin, especially the articular arches and face 50-80

17.10 Mycoses

• for limited skin infestation 0-10

• in case of infestation of all finger and toenails, possibly with destruction of nail plates 20

Chronic recurrent erysipelas

• Without permanent lymphedema 10

• otherwise, depending on the severity of the lymphedema 20-40

Chronic recurrent herpes simplex

• low expansion, recurring up to three times a year 0-10

• greater expansion, more frequent recurrence 20

17.11 Total hair loss

• (with missing eyebrows and eyelashes) 30

17.12 Nevus

• The GdS depends solely on the extent of any disfiguration.

Pigment disorders (e.g. vitiligo) on hands and/or face

• low 10

• Extended 20

17.13 After removal of a malignant skin tumor, the first five years must be allowed to elapse before a cure is found (exceptions: e.g. basal cell carcinoma, Bowen's disease, melanoma in situ);

• GdS during this period after removal of stage I melanoma ([pT1 to T2] pN0 M0) or other stage I skin tumour (pT1 to T2) pN0 to N2 M0 50

• in other stadiums 80

18.2.2 Collagenoses (e.g. systemic lupus erythematosus, progressive systemic sclerosis, polymyositis/dermatomyositis),

18.2.3 Vasculitides (e.g. panarteriitis nodosa, polymyalgia rheumatica)

The assessment of GdS in collagenoses and vasculitides depends on the type and extent of the respective organ involvement and the effects on the general condition, whereby an analogy to muscle diseases may also be considered. For the duration of an aggressive therapy lasting more than six months, a GdS of 50 should not be undershot.

18.3 The assessment of non-inflammatory soft tissue diseases depends on the type and extent of the respective organ involvement and the effects on the general condition.

18.4 Fibromyalgia

Fibromyalgia, Chronic Fatigue Syndrome (CFS), Multiple Chemical Sensitivity (MCS) and similar syndromes must be assessed analogously in each individual case according to their functional effects.

18.6 Muscular diseases

The following functional impairments must be assumed when assessing GdS:

• muscular weakness with minor effects (premature fatigue, uncertainties related to use) 20-40

• with moderate effects (increasing joint contractures and deformities, inability to straighten up from a lying position, impossibility to climb stairs) 50-80

• with severe effects (up to the inability to walk, stand and use the arms) 90-100

Note: In addition, in the case of individual muscle diseases, effects on internal organs (e.g. restriction of lung function and/or heart performance due to chest deformation) or eye muscle, swallowing or speech disorders must be taken into account and, if necessary, evaluated by an expert.

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