General:

Authors’ of the Circular: Dr. Yehuda Sasson and Dr. Olga Hilkowitz, the Medical Office

Participated in drafting the Circular: Dr. Roni Milo, Director of the Neurological Department, Brazilay Medical Center and Dr. Radai Shahin, Director of Neurological Department in Ziv Medical Center.

Circular Approved by: Dr. Ishay Ostfeld (the Medical Director and Chief Doctor).

The Purposes of theCircular:

1. To assist and exhaust the medical rights of multiple sclerosis with the National Insurance Institute.
2. To assist the doctor of the medical committees to assess the multiple sclerosis patients, when determining the disability and fitness rate.

Preamble:

In general, determining a disability is based upon the functional limitations arising from the disease.

Therefore, even for multiple sclerosis patients the disability is based on the various functional disabilities arising from the disease and not the diagnosis itself.

Multiple Sclerosis:

1. Multiple sclerosis is a progressive onslaught disease, whose source is probably an autoimmune problem.
2. The disease affect the myelin and the proper nerve function of the central nervous system.
3. The clinical expressions of the disease change and the nerve damage may involve various systems (motoric, vison, bladder and stool control, etc.).
4. The disease is common amongst young women, aged 15 – 45 and does not impact the life expectancy of individuals suffering from the disease.
5. In Israel, there are about 3,000 – 5,000 multiple sclerosis patients.

Determining Disability for Multiple Sclerosis

1. When reviewing and assessing the disability, it is necessary to examine three typical measures of the disease:

A. Clinically Isolated Syndrome (CIS) – the first (isolated) seizure which is consistent with multiple sclerosis. This stage can be inactive (without additional seizures) or clinically active (as described below). The first seizure usually does not leave any significant disability.

B. Relapsing Remitting -an inactive disease or intermittently active. For these patients, it is necessary to review all the deficiencies caused due to the disease:

• A seizure in the last year

– for these patients it is important to refer to them in the state of an active seizure and review the disability accordingly.

Irregular seizures -patients suffering from multiple sclerosis on a daily basis. For these patients, it is necessary to review all the deficiencies they suffer from, when assessing the disability.

C. Progressive Disease (SPMS or PPMS) – it is necessary to refer to the patients suffering from the disease whose course is progressive an individual suffering from a deteriorating disease on a permanent basis (and note this in the committee’s protocol).

2. The manner in assessing the disability:

A. Due to the varying nature of the disease and the different symptoms, it is important to assess during the medical committee all the systems that may be affected by the disease.

B. Therefore, during every assessment it is pertinent to clarify whether there are additional deficiencies which the patient is not complaining about.

C. Due to the onslaught nature of the disease, it is possible that the patient being examined by the committee will not be in acute stage during the examination. Therefore, it is important to refer to the patient’s condition also during the period before his arrival to the committee.

3. The manner in determining the disability rate:

The degree of the disability will be determined in accordance with the weighted summary of all the deficiencies arising from the disease. Below are examples of the common systematic injuries for medical sclerosis patients and the recommended deficiency clauses:

A. Hemiparesis, Paraparesis and Quadriparesis – according to section 29 (1) (2) (3).

B. Mood swings- according to section 34 (A).

C. Injury to optic nerve (optic neuritis) – according to section 52 (1).

D. Urinary problems -according to section 23 (2).

E. Cognitive impairments -according to section 32A(1).

F. Ataxia – according to section 29(10).

G. Fatigue, sensory disturbances, neuropathic pain – according to section 29 (6) or 29 (6) adjusted.

H. Shaking – according to section 29 (8).

I. Bladder control problems -according to section 15.

J. Sexual dysfunction -according to section 24(8).

K. Psychotic disturbances -according to section 33 (A).

Note – since cognitive disturbances, depression, fatigue, headaches, erectile dysfunction and even speech disturbances may constitute an expression of multiple sclerosis, during the multiple sclerosis patient’s assessment with the National Insurance Institute, it is necessary to proactively clarify if they exist.

4. EDSS Scale:

A. The scale describes the disability scales and the need to use aids, when referring to function, for example, walking, coordination, speech, swallowing, etc.

B. The EDSS value appears at times in clinical information during the patient’s assessment at the clinic and it is possible to receive assistance from the committee, in order to assess the severity of the disability.

Determining Temporary and Permanent Disability

1. Due to the nature of the disease and the varying clinical course, it is possible that at times it will be necessary to determine a temporary disability. On the other hand, it is important to take into consideration the progressive nature of the disease and the patient’s general condition and precede and determine, insofar as necessary, permanent disability.

2. Below is the recommended manner to determine temporary and permanent disability:

A. During the initial period of the onset of the disease’s symptoms, prior to their clarification in a clinical process and the treatment’s results, temporary disability will be determined for a period of up to two years, according to the severity of the various deficiencies.

B. Upon the culmination of the initial time and after the course of the disease has been clarified, permanent disability will be determined in accordance with the severity of the various deficiencies, as defined above.

C. In instances where the frequency of the seizures is rare, it is possible to extend the temporary disability for an additional period. Upon the culmination of this period, it is recommended to determine permanent disability.

D. In cases when the disease is specifically progressive, or in cases when the disease is onslaught with a constant, continuous impact for at least one year, it is necessary to advance the determination for permanent disability.

E. For permanent (irreversible) deficiencies, it is necessary to determine permanent disability.

Working Capacity:

1. When determining working capacity, it is necessary to relate to the severity of the symptoms and the course of the disease.

2. When the seizures are recurring and relapsing or in cases where there is significant functional impairment, it is necessary to determine complete loss of working capacitu.

Special Services and Mobility

1. The doctor must refer to the eligibility for special services and a mobility stipend, if and as necessary initiate the claims in these matters. A mobility stipend claim is examined by the medical committee of the Ministry of Health.

2. When determining special services, it is necessary to refer to the typical deficiencies of multiple sclerosis, for example, the need for personal catheterization and bladder control impairment. In addition, it necessary to take into consideration the difficulty in moving or needing a wheelchair and being totally bedridden.

3. In severe cases of disability (for example, cases where the EDSS is 6.5 and greater, or when the patient is bedridden), it is necessary to determine, at least, 112% eligibility for special services.

4. Claims for a mobility stipend must be initiated in cases when the lower limbs have been injured.

Execution by the Medical Committee on the Basis of Medical Documents, without the Presence of the Patient

1. If the doctor believed that on the basis of the documents before him that it possible to professionally determine (and which will not affect the patient’s medical rights), the disability rate or level of the special services for the patient, and in the event that he received the patient’s consent, he can conduct the diagnosis without the presence of the patient.

2. However, in the event that the doctor will decide that in accordance with the documents before him, it is not possible to make a professional decision, or if the patient’s consent was not received in order to determine his disability on the basis of the documents, the patient will be called to the medical committee, or a medical committee will be determined in the patient’s home (within the scope of a “house call”).

Dr. Ishay Ostfeld

The Medical Director and Chief Doctor.