# Cost Coverage for Acne Inversa (Hidradenitis Suppurativa): How to File a Claim with Your Health Insurance Canonical URL: https://www.acneinversa.life/en/blog/health-insurance-coverage-hidradenitis-suppurativa/ Markdown URL: https://www.acneinversa.life/en/blog/health-insurance-coverage-hidradenitis-suppurativa.md Plain text URL: https://www.acneinversa.life/en/blog/health-insurance-coverage-hidradenitis-suppurativa.txt Language: en Category: Doctor Visits Published: 2026-05-31 Last updated: 2026-05-31 Last editorially reviewed: 2026-05-31 Next scheduled review: 2027-05-31 Author: Dr. rer. nat. Dennis Alexander Kwiatkowski (Biochemist, Scientific Writer and Pharma Expert) Scientific editor: Dr. rer. nat. Dennis Alexander Kwiatkowski Reviewer qualifications: Biochemist, Scientific Writer and Pharma Expert Review scope: Scientific literature, clinical guidelines, sources, and editorial clarity Clinical reviewer: No independent clinical review Tags: Acne Inversa, Hidradenitis Suppurativa, HS, Doctor Visits, Acne inversa, Hidradenitis suppurativa, Health insurance, Statutory health insurance, Cost coverage, Biologics, Rehabilitation > Biologics, surgery, wound care, rehabilitation, and disability status: this guide explains how to prepare claims for acne inversa in Germany. Medical disclaimer: This website is for general educational information only and does not replace medical advice, diagnosis, or treatment. Please speak with qualified medical professionals about symptoms or treatment decisions. ## Article > **A note before you read on.** This article explains the general application > process within Germany's statutory health insurance system (GKV) in plain, > accessible terms. It does not replace individual medical, social-legal, or legal > advice. Specific decisions are made by your treating doctor, your health insurer, > and — in the event of a dispute — the responsible social courts or authorities. Last updated: May 31, 2026. People living with acne inversa (medically: hidradenitis suppurativa) often face two hurdles. The first is the condition itself. The second begins when applications, deadlines, assessments, or rejections come into play. This article explains how the application process generally works, which documents are helpful, and what you can do if a health insurer says no. The focus is on four common pathways: biologics, surgery and wound care, rehabilitation, and disability status. ## Key points at a glance - Several biologics are approved in Germany for adults with moderate to severe acne inversa, including adalimumab, secukinumab, and bimekizumab. - For many benefit claims, the health insurer must decide within three weeks, or within five weeks if it consults the Medical Service (Medizinischer Dienst) and informs you accordingly. - You can generally appeal a rejection within one month. - Well-prepared documentation often determines both speed and success: the medical justification, severity, prior treatments, findings, surgical reports, and a clear record of your burden of disease. - Independent patient counseling services, social welfare associations, and experienced acne inversa centers can ease the burden of difficult applications. ## Why acne inversa requires applications at all Many services under statutory health insurance are provided without a separate application: you visit your dermatologist, receive a prescription, and fill it at the pharmacy. For expensive, specialized, or longer-term services, however, the health insurer often reviews in advance whether the requirements are met. For acne inversa, this can particularly affect: - **Biologics**, i.e., modern anti-inflammatory medications - certain **dressing and wound care products** in larger quantities - **home nursing care** for wound management - **medical rehabilitation** - the **degree of disability (GdB)** and the severe disability certificate, where the application is not filed with the health insurer but with the responsible welfare office (Versorgungsamt) or the relevant state authority Behind this lies the principle of cost-effectiveness in statutory health insurance (Section 12 SGB V): services must be adequate, appropriate, and cost-effective. In practice, this means: the more precisely the medical need is justified and documented, the less room there is for follow-up questions and misunderstandings. ## Pathway 1: Cost coverage for biologics ### Which medications are approved For adults with active, moderate to severe acne inversa who have not responded adequately to conventional systemic therapy, the following biologics, among others, are approved in Germany: | Active ingredient | Examples | Approved since | | --- | --- | --- | | Adalimumab | Humira and biosimilars | 2015 | | Secukinumab | Cosentyx | 2023 | | Bimekizumab | Bimzelx | 2024 | Adalimumab is the biologic that has been approved for acne inversa the longest. For newer active ingredients, health insurers or the Medical Service may ask more detailed questions about whether the requirements are met and why exactly this active ingredient was chosen. Important to know: this does not automatically mean that a newer biologic is "inferior" or not eligible for reimbursement. It simply means the medical justification should be clear, especially if adalimumab was not chosen or has already proven insufficiently effective. ### How the application process works, step by step **Step 1: Medical indication.** Your dermatologist determines whether biologic therapy is medically indicated. Important factors include: - a confirmed diagnosis with the correct diagnosis code **L73.2** - the severity, for example via IHS4 and the Hurley stage - an overview of previous treatments and why they were insufficient - relevant coexisting conditions, intolerances, or contraindications **Step 2: Application to the health insurer.** For many insurers, the application consists of a brief cover letter from you and a medical statement. Submit the documents as completely as possible, since findings submitted later often cost weeks of delay. **Step 3: Deadlines.** Under Section 13 (3a) SGB V, the health insurer must decide on many benefit claims within three weeks. If it consults the Medical Service, the deadline is five weeks. It must inform you of this in good time. If the health insurer misses a deadline without appropriate notice, the application may be deemed approved. However, the legal consequences are not straightforward in detail. If significant costs are involved, seek advice before arranging and paying for a service yourself and later requesting reimbursement. **Practical tip:** Note the date on which the health insurer received your application. Use a member portal with a receipt confirmation, or send important documents in a verifiable manner. **Step 4: The Medical Service.** The Medical Service prepares an assessment. The final decision, however, is still made by the health insurer. You can request the assessment as part of your right to access your file and review it with your doctor. ### What if the medication is off-label? Some therapies are discussed for acne inversa or used in special situations without being specifically approved for this diagnosis. This is known as off-label use. Cost coverage is possible but requires more justification. In such cases, the application should clearly state: - why this is a serious disease situation - which approved alternatives were tried, or why they are not suitable - what scientific basis exists for the expected benefit - why the specific treatment is medically necessary in this individual case A detailed specialist medical justification is worthwhile here, and early social-legal advice is advisable in the event of a rejection. ## Pathway 2: Surgery and wound care In advanced acne inversa, surgery, such as deroofing or extensive removal of the affected tissue, is an important component of treatment. Depending on the situation, such procedures are billed on an outpatient or inpatient basis and often do not require a separate cost-coverage application from you. The medical indication is established by the operating practice or clinic. For everyday life after surgery, aftercare is often the decisive factor: - **Dressing and wound care products** are prescribed by your doctor. For certain other wound treatment products, a transitional rule currently secures their prescribability at the expense of statutory health insurance until the end of 2026. Ask your practice which products are currently prescribable. - **Home nursing care** for wound management can be prescribed if you are unable to carry out the care yourself or if it is particularly medically demanding (Section 37 SGB V). The health insurer reviews this application. **Practical tip:** Keep surgical reports, wound documentation, and photos of the healing process. These can later be important for follow-up applications, rehabilitation applications, and a disability status (GdB) application. ## Pathway 3: Medical rehabilitation Rehabilitation can be sensible if acne inversa significantly impairs your ability to work or your everyday functioning, for example after major surgeries, during long periods of sick leave, with persistent pain, or under severe psychological strain. - If you are employed and covered by pension insurance, the **German Pension Insurance (Deutsche Rentenversicherung)** is often responsible. The application is filed using form **G0100**; medical findings reports supplement the application. - In other circumstances, the **health insurer** may be responsible. In that case, the process usually proceeds through a doctor's prescription for medical rehabilitation. Explain concretely how the condition limits you: pain, restricted mobility, dressing changes, sick days, sleep problems, ability to work, and psychological burden. The pension insurer primarily assesses whether rehabilitation can preserve or restore your ability to work. ## Pathway 4: Degree of disability and severe disability certificate Acne inversa can justify a degree of disability. The application is not filed with the health insurer but with the responsible welfare office (Versorgungsamt) or the relevant state authority. A severe disability certificate is issued from a GdB of 50. Even a GdB of 30 or 40 can be relevant, for example in the case of possible equal treatment in the workplace. What matters is not the diagnosis alone, but the actual functional impact. Acne inversa is not always listed in the Medical Assessment Ordinance (Versorgungsmedizin-Verordnung) under the name that patients use in everyday life. Documentation is therefore especially important: - a symptom and pain diary kept over several weeks - photos showing the progression - surgical reports, doctor's letters, and findings - evidence of wound care, dressing needs, and periods of sick leave - certificates regarding psychological burden or coexisting conditions - a description of concrete limitations, such as when sitting, walking, raising your arms, sleeping, during intimacy, or at work **Practical tip:** If your GdB is set surprisingly low, it is worth having it reviewed. An appeal should not merely repeat the diagnosis but show how severely the condition actually limits your life. ## If the health insurer says no: appeal and litigation A rejection is not the end of the road. **1. File an appeal.** You can generally appeal a decision (Bescheid) within one month (Section 84 SGG). Initially, a short sentence is enough: > I hereby appeal against your decision dated [date]. I will submit a detailed > justification at a later date. This preserves the deadline and gives you time to prepare a detailed justification with your doctor or a counseling service. **Important regarding the deadline:** Since 2025, a decision sent by post is generally considered received on the fourth day after it was mailed (Section 37 SGB X). Calculate deadlines with this in mind. If the notice of legal remedies is missing or incorrect, a longer deadline may apply. **2. Review the assessment.** Request the Medical Service's assessment and check it for factual errors. Common issues include missing findings, incorrectly recorded prior treatments, or an underestimated everyday burden. **3. Litigation before the social court.** If the appeal is also unsuccessful, you can generally file a lawsuit with the social court within one month (Section 87 SGG). In particularly urgent cases, such as an urgently needed operation, temporary legal protection (interim relief) may be considered. **4. If nothing happens at all.** Different deadlines apply for an action for failure to act (Untätigkeitsklage), depending on the stage of proceedings (Section 88 SGG). If a decision on an appeal is not made, such an action is generally possible after three months. For an application that has not yet been decided, Section 88 SGG often provides for a deadline of six months; for many statutory health insurance benefit claims, the special rule of three or five weeks under Section 13 (3a) SGB V may additionally apply. Seek advice if you have questions about deadlines. ## Where to get help You do not have to go down this path alone. The following organizations can offer support: - The [Independent Patient Counseling Service](https://www.patientenberatung.de/) (Unabhängige Patientenberatung) provides guidance on patient rights and insurance questions. - Social welfare associations such as [VdK](https://www.vdk.de/) and [SoVD](https://www.sovd.de/) offer advice on social law and often support members in appeal and litigation proceedings. - Specialized acne inversa centers and experienced dermatology practices can help make applications medically convincing. Our directory of [HS specialists](/en/hs-specialists/) offers a first point of orientation. - Support groups and exchanges with other patients can offer practical tips, but they do not replace legal or medical advice. ## Your application checklist Have these documents ready: - [ ] a current medical statement with diagnosis code **L73.2** - [ ] documentation of severity, for example IHS4 and Hurley stage - [ ] a list of previous treatments, including their effects and side effects - [ ] photographic documentation of the affected areas - [ ] surgical reports, if available - [ ] a pain and symptom diary - [ ] certificates regarding psychological and physical coexisting conditions - [ ] evidence of periods of incapacity to work - [ ] the date your application was received by the health insurer ## Key takeaways Good applications for acne inversa are rarely a mere formality. They translate a chronic, often invisible burden into documents, deadlines, and medical justifications. The more clearly the diagnosis, severity, prior treatments, and everyday limitations are documented, the better the responsible authority can decide. If an application is rejected, review the justification carefully and don't let any deadlines pass. A brief appeal is initially enough to gain time for a stronger justification. ## FAQ ### Do I have to try adalimumab first before I can get a different biologic? Not necessarily. However, if a different biologic is requested as the first biologic therapy, the health insurer may ask why adalimumab was not chosen. A clear medical justification, such as intolerance, a contraindication, or a particular individual finding, makes the application significantly stronger. ### How long can the health insurer take to decide? For many benefit claims, Section 13 (3a) of the German Social Code Book V (SGB V) sets a decision period of three weeks. If the Medical Service (Medizinischer Dienst) is consulted, this extends to five weeks, provided the health insurer informs you in time. The legal consequences of a missed deadline can be complex in individual cases, so you should seek advice before arranging and paying for a service yourself. ### Does filing an appeal cost money? The appeal procedure (Widerspruchsverfahren) is generally free of charge. You may incur costs if you seek legal support. Social welfare associations often provide their members with support and legal protection in social law appeal and litigation proceedings. ### Can I get a severe disability certificate for acne inversa? Yes, this is possible. What matters is not the diagnosis alone, but the documented functional impact, such as pain, repeated surgeries, restricted mobility, wound care, scarring, psychological burden, and coexisting conditions. ## References 1. S2k Guideline on the Therapy of Hidradenitis Suppurativa / Acne Inversa - AWMF, 2024 - https://register.awmf.org/assets/guidelines/013-012l_S2k_Therapie-Hidradenitis-suppurativa-Acne-inversa_2024-08.pdf 2. Secukinumab for Hidradenitis Suppurativa, Early Benefit Assessment - Gemeinsamer Bundesausschuss, 2023 - https://www.g-ba.de/bewertungsverfahren/nutzenbewertung/961/ 3. Bimekizumab for Hidradenitis Suppurativa, Early Benefit Assessment - Gemeinsamer Bundesausschuss, 2024 - https://www.g-ba.de/bewertungsverfahren/nutzenbewertung/1087/ 4. Section 13 SGB V – Cost Reimbursement and Decision Deadlines - Gesetze im Internet - https://www.gesetze-im-internet.de/sgb_5/__13.html 5. Section 37 SGB X – Notification of an Administrative Act - Gesetze im Internet - https://www.gesetze-im-internet.de/sgb_10/__37.html 6. Section 84 SGG – Appeal Deadline - Gesetze im Internet - https://www.gesetze-im-internet.de/sgg/__84.html 7. Section 88 SGG – Action for Failure to Act - Gesetze im Internet - https://www.gesetze-im-internet.de/sgg/__88.html 8. Annex to the Medical Assessment Ordinance (Versorgungsmedizin-Verordnung) - Gesetze im Internet - https://www.gesetze-im-internet.de/versmedv/anlage.html 9. Rehabilitation Application Form G0100 - Deutsche Rentenversicherung - https://www.deutsche-rentenversicherung.de/SharedDocs/Formulare/DE/_pdf/G0100.html