Concern Over Denial of Keytruda for Long-Standing Member with Gastric Cancer

Dear Discovery Health Servicing Team,

I refer to my message dated 17 May 2025, submitted as a private reply on HelloPeter, in which I clearly requested a written and dated response within two working days.

To date, I have received no reply. The matter relates to your repeated refusal to fund pembrolizumab (Keytruda) for my wife, a 43-year-old Discovery member since 2009, who has metastatic gastric cancer with a PD-L1 CPS of 5. She is currently on her fifth cycle of chemotherapy and is experiencing treatment-related hearing loss, tumour bleeding, and was recently admitted to high care. She has also been enrolled in Discovery’s Advanced Illness Benefit (AIB).

This is not an administrative request — it is a matter of medical urgency, governed by your obligations under the Medical Schemes Act, especially Regulation 8(1).

I again respectfully request that Discovery provide:

1. Confirmation of whether this is considered a Prescribed Minimum Benefit (PMB) case.

2. Clarification on whether systemic therapies, including immunotherapy, are covered when clinically indicated.

3. Confirmation that recent trial data (KEYNOTE-590, KEYNOTE-859) and guideline-based evidence have been used in assessing this case.

4. Confirmation whether Discovery has previously funded immunotherapy for members with CPS <10.

Given the medical and legal urgency, I now formally request a written response within 24 hours, failing which this matter will be escalated.

Sincerely,
Malcolm G
Main Member and Husband

HelloPeter Response to Discovery Health
Title: Still No Justified Reason for Denial – Discovery Ignores PMB Law, Evidence, and Clear Questions

Despite Discovery Health’s repeated replies claiming to have “responded,” you have not addressed the actual issues raised. You continue to deny funding for pembrolizumab (Keytruda) for my wife — who has metastatic gastric cancer with PD-L1 CPS 5 — based on an internal CPS ≥10 policy that is not listed in your registered scheme rules or PMB annexures.

This is a Prescribed Minimum Benefit (PMB) under DTP 950C/950D. Regulation 8(1) of the Medical Schemes Act obliges Discovery to fully fund clinically appropriate PMB treatments, regardless of plan type or internal thresholds.

We have asked clear, direct questions in writing — including requests for Discovery to provide:

The regulation or scheme rule supporting the CPS ≥10 exclusion

Why the PMB diagnosis is not being acknowledged

Why chemotherapy-induced hearing loss and clinical deterioration are being ignored

None of these questions have been answered. Instead, Discovery continues to issue generic rejections while sidestepping its legal obligations.

We also note that Discovery has not responded to our Campaign 4 Cancer case manager, who has contacted your team in good faith.

It is deeply disappointing that Discovery continues to deny, deflect, and delay in the face of a lawful, medically supported PMB request for a patient whose condition is deteriorating. We will pursue every regulatory and legal avenue until this is resolved.

"Dear Malcolm, thank you for your patience whilst we looked into this matter.

After a careful and thorough review of the funding request for Keytruda, we regret to inform you that we are unable to approve funding at this time. This decision was, and is still based on the current clinical entry criteria, which unfortunately have not been met in this instance.

Please understand that these criteria are in place to ensure treatments are provided in the safest and most effective manner, in line with established clinical guidelines.

We truly appreciate how challenging this situation must be, and we want to assure you that this decision was made after careful consideration. Regards."

Discovery again fails to answer the questions and provide the data.

1. Confirmation of whether this is considered a Prescribed Minimum Benefit (PMB) case.

2. Clarification on whether systemic therapies, including immunotherapy, are covered when clinically indicated.

3. Confirmation that recent trial data (KEYNOTE-590, KEYNOTE-859) and guideline-based evidence have been used in assessing this case.

4. Confirmation whether Discovery has previously funded immunotherapy for members with CPS <10.

@Discovery_SA — You continue to deny Keytruda for metastatic gastric cancer, citing “current clinical entry criteria” without disclosing what those criteria are.

Why won’t you publish them? What are you hiding?



> The most recent global trial evidence — including KEYNOTE-859 (2023) — supports pembrolizumab + chemo for HER2-negative gastric cancer regardless of PD-L1 CPS ≥1 or ≥5.

Even your own ICON guidelines refer to CPS ≥1 in specific cases.



> My wife has: ✅ Metastatic gastric cancer
✅ PD-L1 CPS = 5
✅ HER2-negative
✅ Severe chemo toxicity

This is medically indicated, and a Prescribed Minimum Benefit (PMB) under DTP 950C.



> You are intentionally avoiding stating why CPS ≥10 is your cutoff — because it’s not backed by CMS, and not defensible in law.



> Stop hiding behind “internal criteria” and justify your decision in clinical and legal terms — or reverse it.



> @CMSZA please investigate.
#PMB #Keytruda #DiscoveryHealth #TransparencyNow

No response. No case manager. No updates.

@Discovery_SA has gone full DEFCON — disappear, delay, deny.

Meanwhile, my wife fights metastatic gastric cancer without the Keytruda she qualifies for under global guidelines.

Shameful.
#PMB #Keytruda #CancerCareCrisis #DiscoveryHealth

Dear Discovery,

Thank you – I have been contacted by three of Discovery’s case managers, who are now actively assisting with the collation of the requested clinical documentation and supporting the appeal process for funding and clinical approval.

It is my understanding that Discovery Health will now conduct a review of this appeal and assess the case fairly and objectively, based on the medical information submitted and in accordance with the relevant provisions of the Prescribed Minimum Benefits (PMB) regulations – considering both the PMB status of metastatic gastric cancer (C16.9 and C22.9) and my wife’s current clinical condition.

We remain hopeful that this matter will be resolved with the urgency and fairness it requires.

Updates will follow.

Regards,
Malcolm G

🩸 Discovery Health Is Not Just Delaying Treatment – They're Withholding Survival

On 29 January 2025, my wife was diagnosed with metastatic gastric cancer (C16.9). Her biopsy confirmed:

✅ PD-L1 CPS = 5
✅ HER2 negative
✅ Ki-67 = 80%
✅ Spread to her liver

Her oncologist prescribed Keytruda (pembrolizumab) — a SAHPRA-approved immunotherapy supported by global guidelines and the KEYNOTE-859 trial. This treatment is intended for patients like her: HER2-negative, PD-L1 positive, and no longer coping with chemotherapy.

🟥 This post now appears on Facebook:
👉 https://www.facebook.com/share/p/1AhPmWYeDr/ 💔 What’s Happened Since She has already endured six rounds of chemotherapy. The consequences:

Still, Discovery Health refuses to authorise the only treatment that meets every clinical and legal requirement. ⚠️ Clinical Evidence Ignored. Biomarkers Misread. Time Wasted. Discovery claimed CPS referred to the Cognitive Performance Scale — a dementia tool.
They completely overlooked her PD-L1 CPS score of 5, the recognised immunotherapy biomarker. Instead of correcting their mistake, they passed the case to SAOC, despite:

🧬 The Advocate Stepped In — And Discovery Ignored Him Too We contacted Campaigning for Cancer (C4C).
Their patient advocate formally asked Discovery to explain why they were applying a “CPS ≥10” threshold — which applies to oesophageal cancer, not gastric cancer.

❓ The Oncology Innovation Benefit — Gone When Needed We were told our plan (Classic Priority) doesn’t qualify for the Oncology Innovation Benefit (OIB). Yet:

Now it’s suddenly... “not applicable”? 🧪 Discovery’s Pattern: Hide Behind Drug Limits, Ignore the Law This isn’t new. Discovery has a habit of hiding behind tiering and internal formularies to avoid paying for PMB-protected treatment. They say things like:

But they never acknowledge:

💬 Can You Really Put a Price on a Life? This isn’t a request for special treatment.
It’s a Prescribed Minimum Benefit, protected by South African law. She qualifies under:

Every day Discovery delays, she loses:

💸 Yes, drugs cost money.
🩺 But you can’t put a price on someone’s right to live without pain. 📎 This Is Now a Legal Fight We’ve filed a formal complaint with the Council for Medical Schemes:
📄 CMS Case No: CMS89941 We will continue to speak out — because if this is happening to us, it’s happening to others.

#KeytrudaForCPS5 #DiscoveryHealth #PMBJustice #C4CIgnored #Campaign4Cancer #CMS89941 #OIBDenial #GastricCancerSA #C16_9 #WhenDelayKills

🛑 Discovery Health is Still Denying My Wife Life-Saving Cancer Treatment – Despite All Evidence

Discovery Health has now issued yet another rejection (23 June 2025) for pembrolizumab (Keytruda) to treat my wife’s metastatic HER2-negative gastric cancer (C16.9) with a PD-L1 CPS of 5.

Despite clear evidence and support from:

Discovery continues to:

In one letter, they even referred to CPS as the “Cognitive Performance Score.”
This is not only clinically inaccurate, it's careless and disrespectful. My wife:

Yet Discovery:

📢 This is not healthcare. It is cost-driven denial disguised as clinical review.
We are escalating this to the Council for Medical Schemes under the DERM enforcement process, and are calling on other patients and families affected to come forward. Enough is enough. #DiscoveryHealth #Keytruda #PMB #HealthcareAccess #GastricCancer #KEYNOTE859 #CPS5 #Regulation8 #CMSComplaint #Oncology #FightForLife #HelloPeter #PatientRights

🔍 EXPLANATION OF DISCOVERY’S LETTER

🟨 Opening Paragraph

> “We regret to inform you that the request for Keytruda cannot be funded for this indication…”



This sets the tone: they are denying funding despite re-evaluation. They reference the KEYNOTE-859 trial, which is the appropriate study for your wife's condition, but they will soon misrepresent its findings.


---

1. 📌 Clinical Evidence from KEYNOTE-859

> “Although the study included patients with a CPS ≥1, the most substantial clinical benefit was observed in patients with CPS ≥10…”



Translation:
They admit your wife meets the minimum inclusion criteria (CPS ≥1), but claim only patients with CPS ≥10 benefit meaningfully.

What's wrong with this?

The regulatory threshold for use (SAHPRA, NCCN, ESMO) is CPS ≥1, not 10.

KEYNOTE-859 showed statistically significant survival benefit even in CPS ≥1 population.

Discovery adds a non-regulatory hurdle (CPS ≥10) to limit access.


> “1.6-month survival benefit…does not meet the Scheme’s minimum threshold for meaningful survival benefit…”



Translation:
Discovery uses a self-defined “meaningful survival” standard, not recognised in global oncology guidelines or local regulatory approvals.

Problem:
This threshold is not legal grounds to deny a PMB treatment registered for use.


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2. 📌 Inclusion Criteria Not Met

> “The patient's CPS of 5 does not meet the threshold outlined in the Scheme’s Clinical and Cost-Effectiveness Matrix…”



Translation:
Their internal rules require a CPS of ≥10 to fund the drug.

What's wrong?

This CCE Matrix is not binding under the Medical Schemes Act.

PMBs must be assessed based on clinical appropriateness, not internal funding rules that override standard of care.


> “Keytruda is indicated in…CPS ≥10” (quoting OIB brochure)



False assertion:
SAHPRA registration and global guidelines say CPS ≥1, not 10. This is a policy invention, not a regulatory or clinical reality.


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3. 📌 Plan Limitations

> “The member’s current benefit plan…does not include Keytruda for the requested indication…”



Translation:
Your Classic Priority plan doesn't offer Keytruda in this context under OIB (Oncology Innovation Benefit).

What’s wrong?

Plan exclusions do not apply to PMBs.

Metastatic gastric cancer is a PMB condition, so the plan type is irrelevant.

Discovery is misusing plan design to block a legally required benefit.



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4. 📌 PMB Fulfilment Review (Conditional and Contradictory)

> “If the request is found to be clinically appropriate… we may review under PMB fulfilment if the member is not currently receiving treatment…”



Translation:
They claim they’ll consider funding only if your wife hasn’t started treatment, even though she already has — which they know.

Why this is misleading:

This clause blocks retrospective funding even for PMB-approved treatment.

It creates a “Catch-22”: start treatment and lose eligibility, delay and risk progression.



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5. 📌 Legal Disclaimer and Final Position

> “This funding outcome in no way questions your clinical judgment… our responsibility is sustainability…”



Translation:
They acknowledge the oncologist’s expertise but override it based on budget priorities.

Underlying intent:
This is a risk-avoidance tactic. They’re trying to frame the denial as rational and evidence-based — when in fact, it violates:

PMB Regulation 8

Section 15I(b) of the Medical Schemes Act (use of lowest-cost clinically appropriate intervention)

SAHPRA’s product registration scope



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🔴 BOTTOM LINE

This letter:

Reinterprets clinical trial data to justify exclusion;

Relies on internal policies that contradict national law;

Tries to deflect blame onto plan limitations;

Offers a conditional PMB process that is both misleading and time-barred;

Presents a legal risk for Discovery if challenged at CMS.

📢 Top 5 Questions Discovery Health Must Answer — The Public Deserves to Know

1.📜 When do Discovery’s internal rules override SAHPRA approval?
Keytruda is SAHPRA-registered for gastric cancer with CPS ≥1. Discovery denies funding based on a CPS ≥10 threshold.
🟩 Who gave Discovery the authority to overrule South Africa’s own medicine regulator?

2.🔬 Why cite a trial for a different cancer to deny gastric treatment?
Discovery justifies denial using an oesophageal cancer study (KEYNOTE-590), while ignoring gastric-specific data and guidelines (KEYNOTE-859, NCCN).
🟩 Is this a clinical error — or intentional misdirection to avoid payment?

3.⚖️ Does Discovery’s tiering system legally override PMB law?
The Medical Schemes Act says PMB treatments must be funded if clinically appropriate — regardless of plan type or internal tiers.
🟩 Is Discovery creating artificial benefit tiers to deny legally protected care?

4.🏥 Why benchmark private medical aid against public sector drug lists?
Discovery claims Keytruda isn’t available in the public sector — but patients pay for private care.
🟩 Why are private members being told to accept state-level care, while paying private-level premiums?

5.⛔ Why deny PMB applications if treatment has already started?
Discovery’s own letter says it “may not consider” funding if the patient has already started treatment.
🟩 Is Discovery asking patients to delay life-saving treatment just to keep their funding options open?

🛑 South Africans deserve clear, lawful, and ethical answers — not corporate silence or redirection.

Please respond to these questions

No rush, Discovery. It’s just stage 4 cancer.
We totally understand you're still figuring out how your “internal protocols” magically outrank SAHPRA. The people want to know.

We still waiting here... Discovery... Delay, decline, deny...

Still No Response from Discovery Health – Urgent PMB Appeal Ignored

This delay is ********, *********, and medically dangerous.

Hi Discovery,

We must not lie. If there was any contact I would have provided an update. Can you please provide the people with an update.

I am sorry I cannot find your email... Kindly provide the date, time and email address used.

Delay decline and deny. Discovery we still waiting for your response. No email received... We must not lie.