Urgent request for correct authorisation of PMB related radiography

I am writing to request your urgent assistance in resolving an issue that has arisen between medical aid provider (GEMS – Authorisation team) and the radiology practice.

The matter concerns the procedural codes submitted for my wife’s recent MRI scans, which are essential for the ongoing management of my wife’s confirmed diagnosis of Multiple Sclerosis (MS).

Following discussions with the medical aid, they have confirmed that they do not dispute the clinical necessity of the scans (which are annual scans used to compare past and present data). However, they have indicated that the procedural codes submitted do not fall within the MS benefit category. As a result, the claims are being processed under my family’s annual benefits rather than the Prescribed Minimum Benefit (PMB). This is concerning, as it results in a steep shortfall that I am now expected to cover, even though the PMB basket should fully cater for these scans.

The codes submitted include:

70553 – MRI Brain Stem W/O & W/Dye

72142 – MRI Neck Spine W/Dye

51410 and 10430 – Other

While I understand that G35 (Multiple Sclerosis) was used as the diagnosis code, the medical aid has advised that the linked procedural codes do not align with the MS benefit basket. This technical mismatch appears to be the root of the issue.

Burger Radiologists has stated that they worked off the information provided in the referral and used the codes accordingly. However, upon reviewing the referral myself, it is clear that MS is explicitly cited, including references such as “RR, on treatment,” which should have guided the coding more accurately.

The medical aid further explained that they rely on the codes submitted to determine benefit eligibility. They used the example that while a patient may have MS, if the codes submitted reflect general or unrelated aspects, they cannot process the claim under PMB. If the scans are indeed MS-related, then the expert radiologist’s coding should have reflected that clearly, that was provided to them.

When asked why the authorisations team didn’t verify the information with the practitioner, I was told that they don’t even have the referral on the system yet they approved the authorisation under annual limits.

They gave me the impression the codes are not in the MS PMB basket. When I contacted they provided, they informed me that is the codes they always use. Please provide us with the correct codes or contact the providers to resolve this dispute.

It appears that the company is presenting a don’t care attitude when it comes to serious health issues. We ask they you take this matter serious and cover the scan under the correct part of our benefits.