STF rules that health plans must cover procedures not included in the ANS list, with exceptions: understand the decision

On Thursday (18), the Federal Supreme Court (STF) ruled that health insurance plans may be required to cover procedures not included in the list of the National Supplementary Health Agency (ANS).

With this decision, the Court considered it constitutional to require operators to cover treatments or procedures not included in the ANS list.

The ANS list already provides for mandatory coverage treatments, but with this decision, the Court considered it constitutional to require operators to cover procedures outside this list, provided that certain parameters are met.

What are the parameters defined by the STF?

For treatment to be authorized even if it is not included in the ANS list, the following five requirements must be met cumulatively

• Prescription of treatment by a licensed physician or dentist;

• No express refusal or pending review of the ANS list;

• No alternative therapy already included in the list;

• Proof of the treatment's efficacy and safety, according to evidence-based medicine;

• Registration with Anvisa.

And in court decisions?

In cases where the matter reaches the courts, the STF has established criteria that must be followed by judges. Failure to comply may lead to the annulment of the court decision.

Among the main requirements are

• Verify whether the beneficiary has previously requested treatment from the operator and whether there has been an unreasonable delay or omission in the response;

• Consult technical information in the database of the Technical Support Center of the Judiciary (NATJUS) before deciding;

• Do not base the decision solely on the user's prescription or medical report;

• If a preliminary injunction is granted in favor of the patient, the judge must notify the ANS about the possible inclusion of the treatment in the list of procedures.

Impacts of the decision: progress or new challenges?

The STF decision represents an important advance for consumers, as it expands access to treatments that could previously be denied by health plans, establishing solid requirements for coverage acceptance by the plan.

However, some questions arise

• Could the new requirements make access to treatment more difficult and bureaucratic?

• Will there be an increase in litigation with the need to prove all requirements?

• Will the additional costs be passed on to users?

Despite the uncertainties, the decision is seen as an achievement, as it expands patient protection and strengthens the right to health, even though it imposes new requirements on consumers, operators, and the judiciary.