ADDENDUM
Regulations to the Medical Schemes Act, 1998
Annexure A: Prescribed Minimum Benefits (PMB)
BRAIN AND NERVOUS SYSTEM
Code:Diagnosis:Treatment:
906AAcute generalised paralysis, including polio and Guillain-BarreMedical management; ventilation and plasmapheresis
341ABasal ganglia, extra-pyramidal disorders; other dystonias nosInitial diagnosis; initiation of medical management
950ABenign and malignant brain tumours, treatableMedical and surgical management, which includes radiation therapy and chemotherapy
49ACompound/depressed fractures of skullCraniotomy/craniectomy
213ADifficulty in breathing, eating, swallowing, bowel, or bladder control due to non-progressive neurological (including spinal) condition or injury Medical and surgical management; ventilation
83AEncephalocele; congenital hydrocephalusShunt; surgery
902AEpilepsy (status epilepticus, initial diagnosis, candidate for neurosurgery)Medical management; ventilation; neurosurgery
211AIntraspinal and intracranial abscessMedical and surgical management
905AMeningitis – acute and subacuteMedical and surgical management
513AMyasthenia gravis; muscular dystrophy; neuro-myopathies nosInitial diagnosis; initiation of medical management; therapy for acute complications and exacerbations
510APeripheral nerve injury with open woundNeuroplasty
940AReversible CNS abnormalities due to other systemic diseaseMedical and surgical management
1ASevere/moderate head injury: haematoma/edema with loss of consciousnessMedical and surgical management; ventilation
84ASpina bifidaSurgical management
941ASpinal cord compression, ishaemia or degenerative disease nosMedical and surgical management
901AStroke – due to haemorrhage, or ischaemiaMedical management; surgery
28ASubarachnoid and intracranial haemorrhage/haematoma; compression of brainMedical and surgical management
305ATetanusMedical management; ventilation
265ATransient cerebral ischemia; life-threatening cerebrovascular conditions nosEvaluation; medical management; surgery
109AVertebral dislocations/fractures, open or closed with injury to spinal cordRepair/reconstruction; medical management; inpatient rehabilitation up to 2 months
684AViral meningitis, encephalitis, myelitis and encephalomyelitisMedical management
EYE
Code:Diagnosis:Treatment:
47BAcute orbital cellulitisMedical and surgical management
394BAngle-closure glaucomaIridectomy; laser surgery; medical and surgical management
586BBell’s palsy; exposure keratoconjunctivitisTarsorrhaphy; medical and surgical management
950BCancer of eye and orbit – treatableMedical and surgical management, which includes radiation therapy and chemotherapy
901BCataract; aphakiaExtraction of cataract; lens implant
911BCorneal ulcer; superficial injury of eye and adnexaConjunctival flap; medical management
405BGlaucoma associated with disorders of the lensSurgical management
386BHerpes zoster and herpes simplex with ophthalmic complicationsMedical management
389BHyphemaRemoval of blood clot; observation
485BInflammation of lacrimal passagesIncision; medical management
909BOpen wound of eyeball and other eye structuresMedical and surgical management
407BPrimary and open angle glaucoma with failed medical managementTrabeculectomy; other surgery
419BPurulent endophthalmitisVitrectomy
922BRetained intraocular foreign bodySurgical management
904BRetinal detachment, tear and other retinal disordersVitrectomy; laser treatment; other surgery
906BRetinal vascular occlusion; central retinal vein occlusionLaser surgery
409BSympathetic uveitis and degenerative disorders and conditions of globe; sight-threatening thyroid optopathy Enucleation; medical management; surgery
EAR, NOSE, MOUTH AND THROAT
Code:Diagnosis:Treatment:
33CAcute and chronic mastoiditisMastoidectomy; medical management
482CAcute otitis mediaMedical and surgical management, including myringotomy
900CAcute upper airway obstruction, including croup, epiglottitis and acute laryngotracheitisMedical management; intubation; tracheostomy
950CCancer of oral cavity, pharynx, nose, ear, and larynx – treatableMedical and surgical management, which includes chemotherapy and radiation therapy
241CCancrum orisMedical and surgical management
38CChoanal atresiaRepair of choanal atresia
133CCholesteatomaMedical and surgical management
910CChronic upper airway obstruction, resulting in cor pulmonaleSurgical and medical management
901CCleft palate and/or cleft lip without airway obstructionRepair
12CDeep open wound of neck, including larynx; fracture of larynx or trachea, openMedical and surgical management; ventilation
346CEpistaxis – not responsive to anterior packingCautery/repair/control haemorrhage
521CForeign body in ear and noseRemoval of foreign body; and medical and surgical management
29CForeign body in pharynx, larynx, trachea, bronchus and oesophagusRemoval of foreign body
339CFracture of face bones, orbit, jaw; injury to optic and other cranial nervesMedical and surgical management
219CLeukoplakia of oral mucosa, including tongueIncision/excision; medical management
132CLife-threatening diseases of pharynx nos, including retropharyngeal abscessMedical and surgical management
457COpen wound of ear-drumTympanoplasty; medical management
240CPeritonsillar abscessIncision and drainage of abscess; tonsillectomy; medical management
347CSialoadenitis; abscess/fistula of salivary glandsSurgery
543CStomatitis, cellulitis and abscess of oral soft tissue; Vincent’s anginaIncision and drainage; medical management
RESPIRATORY SYSTEM
Code:Diagnosis:Treatment:
903DBacterial, viral, fungal pneumoniaMedical management, ventilation
158D# Respiratory failure, regardless of cause# Medical management; oxygen; ventilation
157DAcute asthmatic attack; pneumonia due to respiratory syncytial virus in persons under age 3 Medical management
125DAdult respiratory distress syndrome; inhalation and aspiration pneumoniasMedical management; ventilation
315DAtelectasis (collapse of lung)Medical and surgical management; ventilation
340DBenign neoplasm of respiratory and intrathoracic organsBiopsy; lobectomy; medical management; radiation therapy
950DCancer of lung, bronchus, pleura, trachea, mediastinum and other respiratory organs – treatable Medical and surgical management, which includes chemotherapy and radiation therapy
170DEmpyema and abscess of lungMedical and surgical management
934DFrank haemoptyisisMedical and surgical management
203DHypoplasia and dysplasia of lungMedical and surgical management
900DOpen fracture of ribs and sternum; multiple rib fractures; flail chestMedical and surgical management, ventilation
5DPneumothorax and haemothoraxTube thoracostomy/thoracotomy
HEART AND VASCULATURE
Code:Diagnosis:Treatment:
155EMyocarditis; cardiomyopathy; transposition of great vessels; hypoplastic left heart syndrome Medical and surgical management; cardiac transplant
108EPericarditisMedical and surgical management
907EAcute and subacute ischemic heart disease, including myocardial infarction and unstable angina Medical management; surgery; percutaneous procedures
284EAcute pulmonary heart disease and pulmonary emboliMedical and surgical management
35EAcute rheumatic feverMedical management
908EAneurysm of major artery of chest, abdomen, neck, unruptured or ruptured nosSurgical management
26EArterial embolism/thrombosis: abdominal aorta, thoracic aortaMedical and surgical management
204ECardiac failure: acute or recent deterioration of chronic cardiac failureMedical treatment
98EComplete, corrected and other transposition of great vesselsRepair
97ECoronary artery anomalyAnomalous coronary artery ligation
309EDiseases and disorders of aortic valve nosAortic valve replacement
210EDiseases of endocardium; endocarditisMedical management
314EDiseases of mitral valveValvuloplasty; valve replacement; medical management
902EDisorders of arteries: visceralBypass graft; surgical management
18EDissecting or ruptured aortic aneurysmSurgical management
915EGangrene; severe atherosclerosis of arteries of extremities; diabetes mellitus with peripheral circulatory disease Medical and surgical management including amputation
294EGiant cell arteritis, kawasaki disease, hypersensitivity angiitisMedical management
450EHereditary haemorrhagic telangiectasiaExcision
901EHypertension – acute life-threatening complications and malignant hypertension; renal artery stenosis and other curable hypertension Medical and surgical management
111EInjury to major blood vessels – trunk, head and neck, and upper limbsRepair
19EInjury to major blood vessels of extremitiesLigation
903ELife-threatening cardiac arrhythmiasMedical and surgical management, pacemakers, cardioversion
900ELife-threatening complications of elective cardiac and major vascular proceduresMedical and surgical management
497EMultiple valvular diseaseSurgical management
355EOther aneurysm of artery – peripheralSurgical management
905EOther correctable congenital cardiac conditionsSurgical repair; medical management
100EPatent ductus arteriosus; aortic pulmonary fistula – persistentLigation
209EPhlebitis and thrombophlebitis, deepLigation and division; medical management
914ERheumatic pericarditis; rheumatic myocarditisMedical management
16ERupture of papillary muscleMedical and surgical management
627EShock/hypotension – life threateningMedical management; ventilation
99ETetralogy of fallot (TOF)Total repair tetralogy
93EVentricular septal defect – persistentClosure
GASTRO-INTESTINAL SYSTEM
Code:Diagnosis:Treatment:
920FAnal fissure; anal fistulaFissurectomy; fistulectomy; medical management
41FAbscess of intestineDrain abscess; medical management
489FAcquired hypertrophic pyloric stenosis and other disorders of the stomach and duodenumSurgical management
254FAcute diverticulitis of colonMedical and surgical management, including colon resection
124FAcute vascular insufficiency of intestineColectomy
337FAmoebiasis; typhoidMedical management
264FAnal and rectal polypExcision of polyp
9FAppendicitisAppendectomy
952FCancer of retroperitoneum, peritoneum, omentum and mesentery – treatable Medical and surgical management, which includes chemotherapy and radiation therapy
950CCancer of the gastro-intestinal tract including oesophagus, stomach, bowel, rectum, anus – treatable Medical and surgical management, which includes radiation therapy and chemotherapy
95FCongenital anomalies of upper alimentary tract – excluding tongueMedical and surgical management
214FOesophageal strictureDilation; surgery
516FOesophageal varicesMedical management; surgical shunt; sclerotherapy
902FGastric or intestinal ulcers with haemorrhage or perforationSurgery; endoscopic diagnosis; medical management
901FGastroenteritis and colitis with life-threatening haemorrhage or dehydration, regardless of cause Medical management
6FHernia with obstruction and/or gangrene; uncomplicated hernias under age 18Repair; bowel resection
20FIntestinal obstruction without mention of hernia; symptomatic foreign body in stomach, intestines, colon and rectum Excision; surgery; medical management
232FParalytic ileusMedical management
498FPeritoneal adhesionSurgical management
3FPeritonitis, regardless of causeMedical and surgical management
555FRectal prolapsePartial colectomy
292FRegional enteritis; idiopathic proctocolitis – acute exaccerbations and complications onlyMedical and surgical management
900FRupture of intra-abdominal organRepair; splenectomy; resection
507FThrombosed and complicated haemorrhoidsHaemorrhoidectomy; incision
LIVER, PANCREAS AND SPLEEN
Code:Diagnosis:Treatment:
325GAcute necrosis of liverMedical management
327GAcute pancreatitisMedical management, and where appropriate, surgical management
36GBudd-Chiari syndrome, and other venous embolism and thrombosisThrombectomy/ligation
910GCalculus of bile duct with cholecystitisMedical management; cholecystectomy; other open or closed surgery
950GCancer of liver, biliary system and pancreas – treatableMedical and surgical management
255GCyst and pseudocyst of pancreasDrainage of pancreatic cyst
156GDisorders of bile ductExcision; repair
910GGallstone with cholecystitis and/or jaundiceMedical management; cholecystectomy; other open or closed surgery
743GHepatorenal syndromeMedical management
27GLiver abscess; pancreatic abscessMedical and surgical management
911GLiver failure; hepatic vascular obstruction; inborn errors of liver metabolism; biliary atresiaLiver transplant, other surgery, medical management
231GPortal vein thrombosisShunt
MUSCULOSKELETAL SYSTEM; TRAUMA NOS
Code:Diagnosis:Treatment:
353HAbscess of bursa or tendonIncision and drainage
32HAcute osteomyelitisMedical and surgical management
950HCancer of bones – treatableMedical and surgical management, which includes chemotherapy and radiation therapy
206HChronic osteomyelitisIncision and drainage
902HClosed fractures/dislocations of limb bones/epiphyses – excluding fingers and toesReduction/relocation
85HCongenital dislocation of hip; coxa vara and valga; congenital clubfootRepair/reconstruction
147HCrush injuries of trunk, upper limbs, lower limb, including blood vesselsSurgical management; ventilation; acute renal dialysis
491HDislocations/fractures of vertebral column without spinal cord injuryMedical management; surgical stabilisation
500HDisruptions of the achilles/quadriceps tendonsRepair
178HFracture of hipReduction; hip replacement
445HInjury to internal organsMedical and surgical management
900HOpen fracture/dislocation of bones or jointsReduction/relocation; medical and surgical management
34HPyogenic arthritisMedical and surgical management
901HTraumatic amputation of limbs, hands, feet, and digitsReplantation/amputation
SKIN AND BREAST
Code:Diagnosis:Treatment:
465JAcute lymphadenitisIncision and drainage; medical management
900JBurns, greater than 10% of body surface, or more than 5% involving head, neck, hands, perineum Debridement; free skin graft; medical management
950JCancer of breast – treatableMedical and surgical management, which includes chemotherapy and radiation therapy
954JCancer of skin, excluding malignant melanoma – treatableIf histologically confirmed, medical and surgical management, which includes radiation therapy
952JCancer of soft tissue, including sarcomas and malignancies of the adnexa – treatableMedical and surgical management, which includes chemotherapy and radiation therapy
349JCellulitis and abscesses with risk of organ or limb damage or septicemia if untreated; necrotising fasciitis Medical and surgical management
901JDisseminated bullous skin disease, including pemphigus, pemphigoid, epidermolysis bullosa, epidermolytic hyperkeratosis Medical management
951JLethal midline granulomaMedical management, which includes radiation therapy
953JMalignant melanoma of the skin – treatableMedical and surgical management, which includes radiation therapy
373JNon-superficial open wounds – non life-threateningRepair
356JPyoderma; body, deep-seated fungal infectionsMedical management
112JToxic epidermal necrolysis and staphylococcal scalded skin syndrome; Stevens-Johnson syndrome Medical management
ENDOCRINE, METABOLIC AND NUTRITIONAL
Code:Diagnosis:Treatment:
331KAcute thyroiditisMedical management
951KBenign and malignant tumours of pituitary gland with/without hypersecretion syndromesMedical and surgical management; radiation therapy
30KBenign neoplasm of islets of LangerhansExcision of tumor; medical management
950KCancer of endocrine system, excluding thyroid – treatableMedical and surgical management, which includes chemotherapy and radiation therapy
952KCancer of thyroid – treatable; carcinoid syndromeMedical and surgical management, which includes chemotherapy and radiation therapy
61KCongenital hypothyroidismMedical management
902KDisorders of adrenal secretion nosMedical management; adrenalectomy
447KDisorders of parathyroid gland; benign neoplasm of parathyroid glandMedical and surgical management
904KHyper and hypothyroidism with life-threatening complications or requiring surgeryMedical management; surgery
31KHypoglycemic coma; hyperglycemia; diabetic ketoacidosisMedical management
236KIron deficiency; vitamin and other nutritional deficiencies – life-threateningMedical management
901KLife-threatening congenital abnormalities of carbohydrate, lipid, protein and amino acid metabolism Medical management
903KLife-threatening disorders of fluid and electrolyte balance, nosMedical management
URINARY AND MALE GENITAL SYSTEM
Code:Diagnosis:Treatment:
354LAbscess of prostateTurp; drain abscess
904LAcute and chronic pyelonephritis; renal and perinephric abscessMedical and surgical management
903LAcute glomerulonephritis and nephrotic syndromeMedical management
954LCancer of penis and other male genital organ – treatableMedical and surgical management, which includes chemotherapy and radiation therapy
953LCancer of prostate gland – treatableMedical and surgical management, which includes chemotherapy and radiation therapy
950LCancer of testis – treatableMedical and surgical management, which includes chemotherapy and radiation therapy
952LCancer of urinary system including kidney and bladder – treatableMedical and surgical management, which includes chemotherapy and radiation therapy
906LCongenital anomalies of urinary system – symptomatic and life threateningNephrectomy/repair
901LEnd stage renal disease regardless of causeDialysis and renal transplant where Department of Health criteria are met only (see criteria published in GPS 004-9001)
900LHyperplasia of the prostate, with acute urinary retention or obstructive renal failureTransurethral resection; medical management
905LObstruction of the urogenital tract, regardless of causeCatheterization; surgery; endoscopic removal of obstructing agent: lithotripsy
436LTorsion of testisOrchidectomy; repair
43LTrauma to the urinary system including ruptured bladderCystorrhaphy; suture; repair
289LUreteral fistula (intestinal)Nephrostomy
359LVesicoureteral refluxMedical management; replantation
FEMALE REPRODUCTIVE SYSTEM
Code:Diagnosis:Treatment:
539MAbscesses of Bartholin’s gland and vulvaIncision and drainage; medical management
288MAcute pelvic inflammatory diseaseMedical and surgical management
954MCancer of cervix – treatableMedical and surgical management, which includes radiation therapy and chemotherapy
952MCancer of ovary – treatableMedical and surgical management, which includes chemotherapy and radiation therapy
950MCancer of uterus – treatableMedical and surgical management, which includes chemotherapy and radiation therapy
953MCancer of vagina, vulva and other female genital organs nos – treatableMedical and surgical management, which includes radiation therapy and chemotherapy
960MCervical and breast cancer screeningCervical smears; periodic breast examination
645MCongenital abnormalities of the female genitaliaMedical and surgical management
266MDysplasia of cervix and cervical carcinoma-in-situ; cervical condylomataMedical and surgical management
53MEctopic pregnancySurgery
460MFistula involving female genital tractClosure of fistula
951MHydatidiform mole; choriocarcinomaD and C; hysterectomy; chemotherapy
902MInfertilityMedical and surgical management
528MMenopausal management, anomalies of ovaries, primary and secondary amenorrhoea, female sex hormones abnormalities nos, including hirsutism Medical and surgical management, including hormone replacement therapy
434MNon-inflammatory disorders and benign neoplasms of ovary, fallopian tubes and uterusSalpingectomy; oophorectomy; hysterectomy; medical and surgical management
237MSexual abuse, including rapeMedical management; psychotherapy
903MSpontaneous abortionMedical and surgical management
435MTorsion of ovaryOophorectomy; ovarian cystectomy
530MUterine prolapse; cystoceleSurgical repair
296MVoluntary termination of pregnancyInduced abortion; medical and surgical management
PREGNANCY AND CHILDBIRTH
Code:Diagnosis:Treatment:
67N# Low birth weight (under 1000g) with respiratory difficulties# Medical management not including ventilation
967N# Low birth weight (under 2500 grams and > 1000g) with respiratory difficulties Medical management, including ventilation; intensive care therapy
71NBirth trauma for babyMedical management; surgery
901NCongenital systemic infections affecting the newbornMedical management, ventilation
904NHaematological disorders of the newbornMedical management
54NNecrotizing enterocolitis in newbornMedical and surgical management
74NNeonatal and infant git abnormalities and disorders, including malrotation and atresiaMedical and surgical management
902NNeonatal endocrine, metablic and toxin-induced conditionsMedical management
903NNeurological abnormalities in the newbornMedical management
52NPregnancyAntenatal and obstetric care necessitating hospitalisation, including delivery
56NRespiratory conditions of newbornMedical management; ventilation
HAEMATOLOGICAL, INFECTIOUS AND MISCELLANEOUS SYSTEMIC CONDITIONS
Code:Diagnosis:Treatment:
50SSyphilis – congenital, secondary and tertiaryMedical management
168S# HIV-infection# HIV voluntary counselling and testing
Co-trimoxazole as preventative therapy
Screening and preventative therapy for TB
Diagnosis and treatment of sexually transmitted infections
Pain management in palliative care
Treatment of opportunistic infections
Prevention of mother-to-child transmission of HIV
Post-exposure prophylaxis following occupatiional exposure or sexual assault
260S# Imminent death regardless of diagnosis# Comfort care; pain relief; hydration
113SAcquired haemolytic anaemiasMedical management
901SAcute leukaemias, lymphomasMedical management, which includes chemotherapy, radiation therapy, bone marrow transplantation
277SAnaerobic infections – life-threateningMedical management; hyperbaric oxygen
48SAnaphylactic shockMedical management; ventilation
900SAplastic anaemia; agranulocytosis; other life-threatening hereditary immune deficienciesBone marrow transplantation; medical management
197SBotulismMedical management
338SCholera; rat-bite feverMedical management
196SChronic granulomatous diseaseMedical management, which includes radiation therapy
916SCoagulation defectsMedical management
246SCysticercosis; other systemic cestode infectionMedical management
903SDeep-seated (excluding nail infections), disseminated and systemic fungal infectionsMedical management; surgery
44SErysipelasMedical management
179SHereditary angioedema; angioneurotic ademaMedical and surgical therapy
174SHereditary haemolytic anaemias (eg. sickle cell); dyserythropoietic anaemia (congenital)Medical management
201SHerpetic encephalitis; Reye’s syndromeMedical management
913SImmune compromise nos and associated life-threatening infections nosMedical management
912SLeprosy and other systemic mycobacterial infections, excluding tuberculosisMedical management
336SLeptospirosis; spirochaetal infections nosMedical management
252SLife-threatening anaemia nosMedical management; transfusion
908SLife-threatening conditions due to exposure to the elements, including hypo- and hyperthermia; lightning strikes Medical management
907SLife-threatening rickettsial and other arthropod-borne diseasesMedical management
172SMalaria; trypanosomiasis; other life-threatening parasitic diseaseMedical management
904SMetastatic infections; septicemiaMedical management
910SMultiple myeloma and chronic leukaemiasMedical management; which includes chemotherapy and radiation therapy
247SPoisoning by ingestion, injection, and non-medicinal agentsMedical management
911SSexually transmitted diseases with systemic involvement not
elsewhere specifiedMedical management
128STetanus; anthrax; Whipple’s diseaseMedical management
122SThalassemia and other haemoglobinopathies – treatableMedical management; bone marrow transplant
316SToxic effect of gases, fumes, and vapoursMedical therapy
11STuberculosisDiagnosis and acute medical management; successful transfer to maintenance therapy in accordance with DoH guidelines
937STumour of internal organ (excludes skin): unknown whether benign or malignantBiopsy
15SWhooping cough, diptheriaMedical management
MENTAL ILLNESS
Code:Diagnosis:Treatment:
182TAbuse or dependence on psychoactive substance, including alcoholHospital-based management up to 3 weeks/year
910TAcute stress disorder accompanied by recent significant trauma, including physical or sexual abuse Hospital admission for psychotherapy/counselling up to 3 days, or up to 12 outpatient psychotherapy/counselling contacts
901TAcute stress disorder accompanied by recent significant trauma, including physical or sexual abuse Hospital admission for medical/ psychotherapy up to 3 days; counselling