1 reviews | Active since Mar 2015
Condition is a PMB but declined operation
My husband have a condition 941A on the PMB list - according to law any medical aid should pay. However with all the proof that he needs a operation it was still declined. They requested a quote for what kind of instrumentation will be used during the operation. The ICD10 codes what have been used is on the list of the council of medical schemes. But after they received the quote it was declined and according to the medical aid the instrumentation that is going to be used is not part of the PMB. What does that mean? Nowhere on the council of the medical schemes is there an indication that surgical treatment is not a PMB for his condition. He have already tried medicine and therapy but nothing is working and the last option is a operation. Medical aid is not abiding to the law.
Thank you for your comment.
The Team has responded to your query this afternoon and confirmed that we have have liaised with our Prescribed Minimum Benefit (PMB) Team as well as our Medical Review Team regarding the request.
As you are aware, we do not cover treatment for back and neck conditions under your chosen plan type. We do however agree that the main diagnosis is a PMB condition. When reviewing cover for treatment of a PMB condition, we will fund this in accordance with the specific baskets of care which are set as the equivalent level of care that a patient would receive in a state facility.
In saying this, we have confirmed that the instrumentation requested is not part of the PMB basket of care. Funding for your request has therefore been declined.
The Medical Review Team has confirmed that if a different course of treatment is pursued which does form part of the PMB basket of care for this condition, and it is done at this non-network facility, we will be able to review funding as PMB up to 80% of the Scheme Rate.
We realise that this is not the feedback that you had hoped for however, I trust that the above information clarifies the situation.
Regards
Danita
Thank you for your comment.
The Team has responded to your query this afternoon and confirmed that we have have liaised with our Prescribed Minimum Benefit (PMB) Team as well as our Medical Review Team regarding the request.
As you are aware, we do not cover treatment for back and neck conditions under your chosen plan type. We do however agree that the main diagnosis is a PMB condition. When reviewing cover for treatment of a PMB condition, we will fund this in accordance with the specific baskets of care which are set as the equivalent level of care that a patient would receive in a state facility.
In saying this, we have confirmed that the instrumentation requested is not part of the PMB basket of care. Funding for your request has therefore been declined.
The Medical Review Team has confirmed that if a different course of treatment is pursued which does form part of the PMB basket of care for this condition, and it is done at this non-network facility, we will be able to review funding as PMB up to 80% of the Scheme Rate.
We realise that this is not the feedback that you had hoped for however, I trust that the above information clarifies the situation.
Regards
Danita