Medical Aid – Prescribed Minimum Benefits (PMBs)

All Medical Schemes are mandated as per the Medical Schemes Act to adhere to the list below. The 270 Diagnosis and Treatment Pairs and the list of Chronic Conditions covered are reviewed from time to time by all stakeholders.

Diagnosis and Treatment Pairs constituting the Prescribed Minimum Benefits Package under Section 29(1)(o) of the Medical Schemes Act (as listed in Annexure A of the Act)

Please find the the specific PMBs and Chronic Conditions below, listed by Organ-System chapter.
For more information on Diagnosis and Treatment Pairs and PMBs, visit the Council of Medical Schemes’ website.

Brain and Nervous System

CODE: 906A
DIAGNOSIS: ACUTE GENERALISED PARALYSIS, INCLUDING POLIO AND GUILLAIN-BARRE
TREATMENT: MEDICAL MANAGEMENT; VENTILATION AND PLASMAPHERESIS

CODE: 341A
DIAGNOSIS: BASAL GANGLIA, EXTRA-PYRAMIDAL DISORDERS; OTHER DYSTONIAS NOS
TREATMENT: INITIAL DIAGNOSIS; INITIATION OF MEDICAL MANAGEMENT

CODE: 950A
DIAGNOSIS: BENIGN AND MALIGNANT BRAIN TUMOURS, TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY AND CHEMOTHERAPY

CODE: 49A
DIAGNOSIS: COMPOUND/DEPRESSED FRACTURES OF SKULL
TREATMENT: CRANIOTOMY/CRANIECTOMY

CODE: 213A
DIAGNOSIS: DIFFICULTY IN BREATHING, EATING, SWALLOWING, BOWEL, OR BLADDER CONTROL DUE TO NON-PROGRESSIVE NEUROLOGICAL (INCLUDING SPINAL) CONDITION OR INJURY
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATION

CODE: 83A
DIAGNOSIS: ENCEPHALOCELE; CONGENITAL HYDROCEPHALUS
TREATMENT: SHUNT; SURGERY

CODE: 902A
DIAGNOSIS: EPILEPSY (STATUS EPILEPTICUS, INITIAL DIAGNOSIS, CANDIDATE FOR NEUROSURGERY)
TREATMENT: MEDICAL MANAGEMENT; VENTILATION; NEUROSURGERY

CODE: 211A
DIAGNOSIS: INTRASP1NAL AND INTRACRANIAL ABSCESS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 905A
DIAGNOSIS: MENINGITIS – ACUTE AND SUBACUTE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 513A
DIAGNOSIS: MYASTHENIA GRAVIS; MUSCULAR DYSTROPHY; NEURO-MYOPATHIES NOS
TREATMENT: INITIAL DIAGNOSIS; INITIATION OF MEDICAL MANAGEMENT; THERAPY FOR ACUTE COMPLICATIONS AND EXACERBATIONS

CODE: 510A
DIAGNOSIS: PERIPHERAL NERVE INJURY WITH OPEN WOUND
TREATMENT: NEUROPLASTY

CODE: 940A
DIAGNOSIS: REVERSIBLE CNS ABNORMALITIES DUE TO OTHER SYSTEMIC DISEASE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 1A
DIAGNOSIS: SEVERE/MODERATE HEAD INJURY: HEMATOMA/EDEMA WiTH LOSS OF CONSCIOUSNESS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATION

CODE: MA
DIAGNOSIS: SPINA BIFIDA
TREATMENT: SURGICAL MANAGEMENT

CODE: 941A
DIAGNOSIS: SPINAL CORD COMPRESSION, ISHAEMIA OR DEGENERATIVE DISEASE NOS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 901A
DIAGNOSIS: STROKE – DUE TO HAEMORRHAGE, OR ISCHAEMIA
TREATMENT: MEDICAL MANAGEMENT; SURGERY

CODE: 28A
DIAGNOSIS: SUBARACHNOID AND INTRACRANIAL HEMORRHAGE/HEMATOMA; COMPRESSION OF BRAIN
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 305A
DIAGNOSIS: TETANUS
TREATMENT: MEDICAL MANAGEMENT; VENTILATION

CODE: 265A
DIAGNOSIS: TRANSIENT CEREBRAL ISCHEMIA; LIFE-THREATENING CEREBROVASCULAR CONDITIONS NOS
TREATMENT: EVALUATION; MEDICAL MANAGEMENT; SURGERY

CODE: 109A
DAGNOSIS: VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR CLOSED WITH INJURY TO SPINAL CORD
TREATMENT: REPAIR/RECONSTRUCTION; MEDICAL MANAGEMENT; INPATIENT REHABILITATION UP TO 2 MONTHS

CODE: 684A
DIAGNOSIS: VIRAL MENINGITIS, ENCEPHAUTIS, MYELITIS AND ENCEPHALOMYELITIS
TREATMENT: MEDICAL MANAGEMENT
CODE: 47B
DIAGNOSIS: ACUTE ORBITAL CELLULITIS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 394B
DIAGNOSIS: ANGLE-CLOSURE GLAUCOMA
TREATMENT: IRIDECTOMY; LASER SURGERY; MEDICAL AND SURGICAL MANAGEMENT

CODE: 586B
DIAGNOSIS: BELL’S PALSY; EXPOSURE KERATOCONJUNCTIVITIS
TREATMENT: TARSORRHAPHY; MEDICAL AND SURGICAL MANAGEMENT

CODE: 950B
DIAGNOSIS: CANCER OF EYE & ORBIT – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY AND CHEMOTHERAPY

CODE: 901 B
DIAGNOSIS: CATARACT; APHAKIA
TREATMENT: EXTRACTION OF CATARACT; LENS IMPLANT

CODE: 911B
DIAGNOSIS: CORNEAL ULCER; SUPERFICIAL INJURY OF EYE AND ADNEXA
TREATMENT: CONJUNCTIVAL FLAP; MEDICAL MANAGEMENT

CODE: 4058
DIAGNOSIS: GLAUCOMA ASSOCIATED WITH DISORDERS OF THE LENS
TREATMENT: SURGICAL MANAGEMENT

CODE: 386B
DIAGNOSIS: HERPES ZOSTER & HERPES SIMPLEX WITH OPHTHALMIC COMPLICATIONS
TREATMENT: MEDICAL MANAGEMENT

CODE: 389B
DIAGNOSIS: HYPHEMA
TREATMENT: REMOVAL OF BLOOD CLOT; OBSERVATION

CODE: 4858
DIAGNOSIS: INFLAMMATION OF LACRIMAL PASSAGES
TREATMENT: INCISION; MEDICAL MANAGEMENT

CODE: 909B
DIAGNOSIS: OPEN WOUND OF EYEBALL AND OTHER EYE STRUCTURES
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 407B
DIAGNOSIS: PRIMARY AND OPEN ANGLE GLAUCOMA WITH FAILED MEDICAL MANAGEMENT
TREATMENT: TRABECULECTOMY; OTHER SURGERY

CODE: 4198
DIAGNOSIS: PURULENT ENDOPHTHALMITIS
TREATMENT: VITRECTOMY

CODE: 922B
DIAGNOSIS: RETAINED INTRAOCULAR FOREIGN BODY
TREATMENT: SURGICAL MANAGEMENT

CODE: 904B
DIAGNOSIS: RETINAL DETACHMENT, TEAR AND OTHER RETINAL DISORDERS
TREATMENT: VITRECTOMY; LASER TREATMENT; OTHER SURGERY

CODE: 906B
DIAGNOSIS: RETINAL VASCULAR OCCLUSION; CENTRAL RETINAL VEIN OCCLUSION
TREATMENT: LASER SURGERY

CODE: 4098
DIAGNOSIS: SYMPATHETIC UVEITIS AND DEGENERATIVE DISORDERS AND CONDITIONS OF GLOBE; SIGHT THREATENING THYROID OPTOPATHY
TREATMENT: ENUCLEATION; MEDICAL MANAGEMENT; SURGERY

Ear, Nose, Mouth and Throat

CODE: 33C
DIAGNOSIS: ACUTE AND CHRONIC MASTOIDITIS
TREATMENT: MASTOIDECTOMY; MEDICAL MANAGEMENT

CODE: 482C
DIAGNOSIS: ACUTE OTITIS MEDIA
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, INCLUDING MYRINGOTOMY

CODE: 900C
DIAGNOSIS: ACUTE UPPER AIRWAY OBSTRUCTION, INCLUDING CROUP, EPIGLOTTITIS AND ACUTE LARYNGOTRACHEITIS
TREATMENT: MEDICAL MANAGEMENT; INTUBATION; TRACHEOSTOMY

CODE: 950C
DIAGNOSIS: CANCER OF ORAL CAVITY, PHARYNX, NOSE, EAR, AND LARYNX – TREATABLE.
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 241C
DIAGNOSIS: CANCRUM ORIS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 38C
DIAGNOSIS: CHOANAL ATRESIA
TREATMENT: REPAIR OF CHOANAL ATRESIA

CODE: 133C
DIAGNOSIS: CHOLESTEATOMA
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 910C
DIAGNOSIS: CHRONIC UPPER AIRWAY OBSTRUCTION, RESULTING IN CORPULMONALE
TREATMENT: SURGICAL AND MEDICAL MANAGEMENT

CODE: 901C
DIAGNOSIS: CLEFT PALATE AND/OR CLEFT LIP WITHOUT AIRWAY OBSTRUCTION
TREATMENT: REPAIR

CODE: 12C
DIAGNOSIS: DEEP OPEN WOUND OF NECK, INCLUDING LARYNX; FRACTURE OF LARYNX OR TRACHEA, OPEN
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATION

CODE: 346C
DIAGNOSIS: EPISTAXIS – NOT RESPONSIVE TO ANTERIOR PACKING
TREATMENT: CAUIERY / REPAIR / CONTROL HEMORRHAGE

CODE: 521C
DIAGNOSIS: FOREIGN BODY IN EAR & NOSE
TREATMENT: REMOVAL OF FOREIGN BODY; AND MEDICAL AND SURGICAL MANAGEMENT

CODE: 29C
DIAGNOSIS: FOREIGN BODY IN PHARYNX, LARYNX, TRACHEA, BRONCHUS & ESOPHAGUS
TREATMENT: REMOVAL OF FOREIGN BODY

CODE: 339C
DIAGNOSIS: FRACTURE OF FACE BONES, ORBIT, JAW; INJURY TO OPTIC AND OTHER CRANIAL NERVES
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 219C
DIAGNOSIS: LEUKOPLAKIA OF ORAL MUCOSA, INCLUDING TONGUE
TREATMENT: INCISION/EXCISION; MEDICAL MANAGEMENT.

CODE: 132C
DIAGNOSIS: LIFE-THREATENING DISEASES OF PHARYNX NOS, INCLUDING RETROPHARYNGEAL ABSCESS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 457C
DIAGNOSIS: OPEN WOUND OF EAR-DRUM
TREATMENT: TYMPANOPLASTY; MEDICAL MANAGEMENT

CODE: 240C
DIAGNOSIS: PERITONSILLAR ABSCESS
TREATMENT: INCISION AND DRAINAGE OF ABSCESS; TONSILLECTOMY; MEDICAL MANAGEMENT

CODE: 347C
DIAGNOSIS: SIALOADENITIS; ABSCESS / FISTULA OF SALIVARY GLANDS
TREATMENT: SURGERY

CODE: 543C
DIAGNOSIS: STOMATITIS, CELLULITIS AND ABSCESS OF ORAL SOFT TISSUE; VINCENTS ANGINA
TREATMENT: INCISION AND DRAINAGE; MEDICAL MANAGEMENT

Respiratory System

CODE: 903D
DIAGNOSIS: BACTERIAL, VIRAL, FUNGAL PNEUMONIA
TREATMENT: MEDICAL MANAGEMENT, VENTILATION.

CODE: 158D
DIAGNOSIS: # RESPIRATORY FAILURE, REGARDLESS OF CAUSE
TREATMENT: # MEDICAL MANAGEMENT; OXYGEN; VENTILATION

CODE: 157D
DIAGNOSIS: ACUTE ASTHMATIC AUACK; PNEUMONIA DUE TO RESPIRATORY SYNCYTIAL VIRUS IN PERSONS UNDER AGE 3
TREATMENT: MEDICAL MANAGEMENT

CODE: 125D
DIAGNOSIS: ADULT RESPIRATORY DISTRESS SYNDROME; INHALATION AND ASPIRATION PNEUMONIAS
TREATMENT: MEDICAL MANAGEMENT; VENTILATION

CODE: 315D
DIAGNOSIS: ATELECTASIS (COLLAPSE OF LUNG)
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATION

CODE: MOD
DIAGNOSIS: BENIGN NEOPLASM OF RESPIRATORY AND INTRATHORACIC ORGANS
TREATMENT: BIOPSY; LOBECTOMY; MEDICAL MANAGEMENT; RADIATION THERAPY

CODE: 950D
DIAGNOSIS: CANCER OF LUNG, BRONCHUS, PLEURA, TRACHEA, MEDIASTINUM & OTHER RESPIRATORY ORGANS -TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 1 7OD
DIAGNOSIS: EMPYEMA AND ABSCESS OF LUNG
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 934D
DIAGNOSIS: FRANK HAEMOPTYISIS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 2O3D
DIAGNOSIS: HYPOPLASIA AND DYSPLASIA OF LUNG
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 900D
DIAGNOSIS: OPEN FRACTURE OF RIBS AND STERNUM; MULTIPLE RIB FRACTURES; FLAIL CHEST
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, VENTILATION

CODE: SD
DIAGNOSIS: PNEUMOTHORAX AND HAEMOTHORAX.
TREATMENT: TUBE THORACOSTOMY / THORACOTOMY

Heart and Vasculature

CODE: 155E
DIAGNOSIS: MYOCARDITIS; CARDIOMYOPATHY; TRANSPOSITION OF GREAT VESSELS; HYPOPLASTIC LEFT HEART SYNDROME.
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT; CARDIAC TRANSPLANT

CODE: 108E
DIAGNOSIS: PERICARDITIS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 907E
DIAGNOSIS: ACUTE AND SUBACUTE ISCHEMIC HEART DISEASE, INCLUDING MYOCARDIAL INFARCTION AND UNSTABLE ANGINA
TREATMENT: MEDICAL MANAGEMENT; SURGERY; PERCUTANEOUS PROCEDURES

CODE: 284E
DIAGNOSIS: ACUTE PULMONARY HEART DISEASE AND PULMONARY EMBOLI
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 35E
DIAGNOSIS: ACUTE RHEUMATIC FEVER
TREATMENT: MEDICAL MANAGEMENT

CODE: 908E
DIAGNOSIS: ANEURYSM OF MAJOR ARTERY OF CHEST, ABDOMENI NECK, -UNRUPTURED OR RUPTURED NOS
TREATMENT: SURGICAL MANAGEMENT

CODE: 26E
DIAGNOSIS: ARTERIAL EMBOLISM/THROMBOSIS: ABDOMINAL AORTA, THORAC1C AORTA
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 204E
DIAGNOSIS: CARDIAC FAILURE: ACUTE OR RECENT DETERIORATION OF CHRONIC CARDIAC FAILURE
TREATMENT: MEDICALTREATMENT

CODE: 98E
DIAGNOSIS: COMPLETE, CORRECTED AND OTHER TRANSPOSTION OF GREAT VESSELS
TREATMENT: REPAIR

CODE: 97E
DIAGNOSIS: CORONARY ARTERY ANOMALY
TREATMENT: ANOMALOUS CORONARY ARTERY LIGATION

CODE: 309E
DIAGNOSIS: DISEASES AND DISORDERS OF AORTIC VALVE NOS
TREATMENT: AORTIC VALVE REPLACEMENT

CODE: 210E
DIAGNOSIS: DISEASES OF ENDOCARDIUM; ENDOCARDITIS
TREATMENT: MEDICAL MANAGEMENT

CODE: 314E
DIAGNOSIS: DISEASES OF MITRAL VALVE
TREATMENT: VALVULOPLASTY; VALVE REPLACEMENT; MEDICAL MANAGEMENT

CODE: 902E
DIAGNOSIS: DISORDERS OF ARTERIES: VISCERAL
TREATMENT: BYPASS GRAFT; SURGICAL MANAGEMENT

CODE: 18E
DIAGNOSIS: DISSECTING OR RUPTURED AORTIC ANEURYSM
TREATMENT: SURGICAL MANAGEMENT

CODE: 915E
DIAGNOSIS: GANGRENE; SEVERE ATHEROSCLEROSIS OF ARTERIES OF EXTREMITIES; DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISEASE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT INCLUDING AMPUTATION

CODE: 294E
DIAGNOSIS: GIANT CELL ARTERITIS, KAWASAKI DISEASE, HYPERSENSITIVITY ANGIITIS
TREATMENT: MEDICAL MANAGEMENT

CODE: 450E
DIAGNOSIS: HEREDITARY HEMORRHAGIC TELANGIECTASIA
TREATMENT: EXCISION

CODE: 901E
DIAGNOSIS: HYPERTENSION – ACUTE LIFE-THREATENING COMPLICATIONS AND MALIGNANT HYPERTENSION; RENAL ARTERY STENOSIS AND OTHER CURABLE HYPERTENSION
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 111E
DIAGNOSIS: INJURY TO MAJOR BLOOD VESSELS – TRUNK, HEAD AND NECK, AND UPPER LIMBS
TREATMENT: REPAIR

CODE: 19E
DIAGNOSIS: INJURY TO MAJOR BLOOD VESSELS OF EXTREMITIES
TREATMENT: LIGATION

CODE: 903E
DIAGNOSIS: LIFE-THREATENING CARDIAC ARRHYTHMIAS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, PACEMAKERS, CARDIOVERSION

CODE: 900E
DIAGNOSIS: LIFE-THREATENING COMPLICATIONS OF ELECTIVE CARDIAC AND MAJOR VASCULAR PROCEDURES
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 497E
DIAGNOSIS: MULTIPLE VALVULAR DISEASE
TREATMENT: SURGICAL MANAGEMENT

CODE: 355E
DIAGNOSIS: OTHER ANEURYSM OF ARTERY – PERIPHERAL
TREATMENT: SURGICAL MANAGEMENT

CODE: 905E
DIAGNOSIS: OTHER CORRECTABLE CONGENITAL CARDIAC CONDITIONS
TREATMENT: SURGICAL REPA!R; MEDICAL MANAGEMENT

CODE: 100E
DIAGNOSIS: PATENT DUCTUS ARTERIOSUS; AORTIC PULMONARY FISTULA – PERSISTENT
TREATMENT: LIGATION

CODE: 209E
DIAGNOSIS: PHLEBITIS & THROMBOPHLEBITIS, DEEP
TREATMENT: LIGATION AND DIVISION; MEDICAL MANAGEMENT

CODE: 914E
DIAGNOSIS: RHEUMATIC PERICARDITIS; RHEUMATIC MYOCARDITIS
TREATMENT: MEDICAL MANAGEMENT

CODE: 16E
DIAGNOSIS: RUPTURE OF PAP1LLARY MUSCLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 627E
DIAGNOSIS: SHOCK / HYPOTENSION – LIFE THREATENING
TREATMENT: MEDICAL MANAGEMENT; VENTILATION

CODE: 99E
DIAGNOSIS: TETRALOGY OF FALLOT (TOF)
TREATMENT: TOTAL REPAIR TETRALOGY

CODE: 93E
DIAGNOSIS: VENTRICULAR SEPTAL DEFECT – PERSISTENT
TREATMENT: CLOSURE

Gastro-Intestinal System

CODE: 920F
DIAGNOSIS: ANAL FISSURE; ANAL FISTULA
TREATMENT: FISSURECTOMY; FISTULECTOMY; MEDICAL MANAGEMENT

CODE: 41F
DIAGNOSIS: ABSCESS OF INTESTINE
TREATMENT: DRAIN ABSCESS; MEDICAL MANAGEMENT

CODE: 489F
DIAGNOSIS: ACQUIRED HYPERTROPHIC PYLORIC STENOSIS AND OTHER DISORDERS OF THE STOMACH AND DUODENUM
TREATMENT: SURGICAL MANAGEMENT

CODE: 254F
DIAGNOSIS: ACUTE DIVERTICULITIS OF COLON
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, INCLUDING COLON RESECTION

CODE: 124F
DIAGNOSIS: ACUTE VASCULAR INSUFFICIENCY OF INTESTINE
TREATMENT: COLECTOMY

CODE: 337F
DIAGNOSIS: AMOEBIASIS; TYPHOID
TREATMENT: MEDICAL MANAGEMENT

CODE: 264F
DIAGNOSIS: ANAL AND RECTAL POLYP
TREATMENT: EXCISION OF POLYP

CODE: 9F
DIAGNOSIS: APPENDICITIS
TREATMENT: APPENDECTOMY

CODE: 952F
DIAGNOSIS: CANCER OF RETROPERITONEUM, PERITONEUM, OMENTUM & MESENTERY – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 950C
DIAGNOSIS: CANCER OF THE GASTRO-INTESTINAL TRACT INCLUDING OESOPHAGUS, STOMACH, BOWEL, RECTUM, ANUS – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY AND CHEMOTHERAPY

CODE: 9SF
DIAGNOSIS: CONGENITAL ANOMALIES OF UPPER ALIMENTARY TRACT – EXCLUDING TONGUE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 214F
DIAGNOSIS: OESOPHAGEAL STRICTURE
TREATMENT: DILATION; SURGERY

CODE: S16F
DIAGNOSIS: ESOPHAGEAL VARICES
TREATMENT: MEDICAL MANAGEMENT; SURGICAL SHUNT; SCLEROTHERAPY

CODE: 9O2F
DIAGNOSIS: GASTRIC OR INTESTINAL ULCERS WITH HEMORRHAGE OR PERFORATION
TREATMENT: SURGERY; ENDOSCOPIC DIAGNOSIS; MEDICAL MANAGEMENT

CODE: 901F
DIAGNOSIS: GASTROENTERITIS AND COLITIS WITH LIFE-THREATENING HAEMORRHAGE OR DEHYDRATION, REGARDLESS OF CAUSE
TREATMENT: MEDICAL MANAGEMENT

CODE: 6F
DIAGNOSIS: HERNIA WITH OBSTRUCTION AND/OR GANGRENE; UNCOMPLICATED HERNIAS UNDER AGE 18
TREATMENT: REPAIR; BOWEL RESECTION

CODE: 20F
DIAGNOSIS: INTESTINAL OBSTRUCTION WITHOUT MENTION OF HERNIA; SYMPTOMATIC FOREIGN BODY IN STOMACH, INTESTINES, COLON & RECTUM
TREATMENT: EXCISION; SURGERY; MEDICAL MANAGEMENT

CODE: 232F
DIAGNOSIS: PARALYTIC 1LEUS
TREATMENT: MEDICAL MANAGEMENT

CODE: 498F
DIAGNOSIS: PERITONEAL ADHESION
TREATMENT: SURGICAL MANAGEMENT

CODE: 3F
DIAGNOSIS: PERITONITIS, REGARDLESS OF CAUSE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 555F
DIAGNOSIS: RECTAL PROLAPSE
TREATMENT: PARTIAL COLECTOMY

CODE: 292F
DIAGNOSIS: REGIONAL ENTERITIS; IDIOPATHIC PROCTOCOLITIS – ACUTE EXACCERBATIONS AND COMPLICATIONS ONLY
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 900F
DIAGNOSIS: RUPURE OF INTRA-ABDOMINAL ORGAN
TREATMENT: REPAIR; SPLENECTOMY; RESECTION

CODE: 5OYF
DIAGNOSIS: THROMBOSED AND COMPLICATED HEMORRHOIDS
TREATMENT: HEMORRHOIDECTOMY; INCISION

Liver, Pancreas and Spleen

CODE: 32SG
DIAGNOSIS: ACUTE NECROSIS OF LIVER
TREATMENT: MEDICAL MANAGEMENT

CODE: 327G
DIAGNOSIS: ACUTE PANCREATITIS
TREATMENT: MEDICAL MANAGEMENT, AND WHERE APPROPRIATE, SURGICAL MANAGEMENT

CODE: 36G
DIAGNOSIS: BUDD-CHIARI SYNDROME, AND OTHER VENOUS EMBOLISM AND THROMBOSIS
TREATMENT: THROMBECTOMY/LIGATION

CODE: 910G
DIAGNOSIS: CALCULUS OF BILE DUCT WITH CHOLECYSTITIS
TREATMENT: MEDICAL MANAGEMENT; CHOLECYSTECTOMY; OTHER OPEN OR CLOSED SURGERY

CODE: 950G
DIAGNOSIS: CANCER OF LIVER, BILIARY SYSTEM AND PANCREAS – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 255G
DIAGNOSIS: CYST AND PSEUDOCYST OF PANCREAS
TREATMENT: DRAINAGE OF PANCREATIC CYST

CODE: 156G
DIAGNOSIS: DISORDERS OF BILE DUCT
TREATMENT: EXCISION; REPAIR

CODE: 910G
DIAGNOSIS: GALLSTONE WITH CHOLECYSTITIS AND/OR JAUNDICE
TREATMENT: MEDICAL MANAGEMENT; CHOLECYSTECTOMY; OTHER OPEN OR CLOSED SURGERY

CODE: 743G
DIAGNOSIS: HEPATORENAL SYNDROME
TREATMENT: MEDICAL MANAGEMENTS

CODE: 27G
DIAGNOSIS: LIVER ABSCESS; PANCREATIC ABSCESS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 911G
DIAGNOSIS: LIVER FAILURE; HEPATIC VASCULAR OBSTRUCTION; INBORN ERRORS OF LIVER METABOLISM; BILIARY ATRESIA
TREATMENT: LIVER TRANSPLANT, OTHER SURGERY, MEDICAL MANAGEMENT

CODE: 231G
DIAGNOSIS: PORTAL VEIN THROMBOSIS
TREATMENT: SHUNT

Musculoskeletal System: Trauma Nos

CODE: 353H
DIAGNOSIS: ABSCESS OF BURSA OR TENDON
TREATMENT: INCISION AND DRAINAGE

CODE: 32H
DIAGNOSIS: ACUTE OSTEOMYELITIS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 950H
DIAGNOSIS: CANCER OF BONES – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 206H
DIAGNOSIS: CHRONIC OSTEOMYELITIS
TREATMENT: INCISION & DRAINAGE

CODE: 902H
DIAGNOSIS: CLOSED FRACTURES/DISLOCATIONS OF LIMB BONES / EPIPHYSES – EXCLUDING FINGERS AND TOES
TREATMENT: REDUCTION/RELOCATION

CODE: 85H
DIAGNOSIS: CONGENITAL DISLOCATION OF HIP; COXA VARA & VALGA; CONGENITAL CLUBFOOT
TREATMENT: REPAIR/RECONSTRUCTION

CODE: 147H
DIAGNOSIS: CRUSH INJURIES OF TRUNK, UPPER LIMBS, LOWER LIMB, INCLUDING BLOOD VESSELS
TREATMENT: SURGICAL MANAGEMENT; VENTILATION; ACUTE RENAL DIALYSIS

CODE: 491H
DIAGNOSIS: DISLOCATIONS/FRACTURES OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY
TREATMENT: MEDICAL MANAGEMENT; SURGICAL STABILISATION

CODE: 500H
DIAGNOSIS: DISRUPTIONS OF THE ACHILLES / QUADRICEPS TENDONS
TREATMENT: REPAIR

CODE: 178H
DIAGNOSIS: FRACTURE OF HIP
TREATMENT: REDUCTION; HIP REPLACEMENT

CODE: 445H
DIAGNOSIS: INJURY TO INTERNAL ORGANS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 900H
DIAGNOSIS: OPEN FRACTURE/DISLOCATION OF BONES OR JOINTS
TREATMENT: REDUCTION/RELOCATION; MEDICAL AND SURGICAL MANAGEMENT

CODE: 34H
DIAGNOSIS: PYOGENIC ARTHRITIS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 901H
DIAGNOSIS: TRAUMATIC AMPUTATION OF LIMBS, HANDS, FEET, AND DIGITS
TREATMENT: REPLANTATION/AMPUTATION

Skin and Breast

CODE: 465J
DIAGNOSIS: ACUTE LYMPHADENITIS
TREATMENT: INCISION AND DRAINAGE; MEDICAL MANAGEMENT

CODE: 900J
DIAGNOSIS: BURNS, GREATER THAN 10% OF BODY SURFACE, OR MORE THAN 5% INVOLVING HEAD, NECK, HANDS, PERINEUM
TREATMENT: DEBRIDEMENT; FREE SKIN GRAFT; MEDICAL MANAGEMENT

CODE: 950J
DIAGNOSIS: CANCER OF BREAST – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 954J
DIAGNOSIS: CANCER OF SKIN, EXCLUDING MALIGNANT MELANOMA – TREATABLE
TREATMENT: IF HISTOLOGICALLY CONFIRMED, MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY.

CODE: 952J
DIAGNOSIS: CANCER OF SOFT TISSUE, INCLUDING SARCOMAS AND MALIGNANCIES OF THE ADNEXA -TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 349J
DIAGNOSIS: CELLULITIS AND ABSCESSES WITH RISK OF ORGAN OR LIMB DAMAGE OR SEPTICEMIA IF UNTREATED; NECROTISING FASCIITIS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 901J
DIAGNOSIS: DISSEMINATED BULLOUS SKIN DISEASE, INCLUDING PEMPHIGUS, PEMPHIGOID, EPIDERMOLYSIS BULLOSA, EPIDERMOLYTIC HYPERKERATOSIS
TREATMENT: MEDICAL MANAGEMENT

CODE: 951J
DIAGNOSIS: LETHAL MIDLINE GRANULOMA
TREATMENT: MEDICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY

CODE: 953J
DIAGNOSIS: MALIGNANT MELANOMA OF SKIN TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY.

CODE: 373J
DIAGNOSIS: NON-SUPERFICIAL OPEN WOUNDS – NON LIFE-THREATENING
TREATMENT: REPAIR

CODE: 356J
DIAGNOSIS: PYODERMA; BODY, DEEP-SEATED FUNGAL INFECTIONS
TREATMENT: MEDICAL MANAGEMENT~

CODE: 112J
DIAGNOSIS: TOXIC EPIDERMAL NECROLYSIS AND STAPHYLOCOCCAL SCALDED SKIN SYNDROME; STEVENS-JOHNSON SYNDROME
TREATMENT: MEDICAL MANAGEMENT

Endocrine, Metabolic and Nutritional

CODE: 331K
DIAGNOSIS: ACUTE THYROIDITIS
TREATMENT: MEDICAL MANAGEMENT

CODE: 951K
DIAGNOSIS: BENIGN AND MALIGNANT TUMOURS OF PITUITARY GLAND WITH/WITHOUT HYPERSECRETION SYNDROMES
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT; RADIATION THERAPY

CODE: 30K
DIAGNOSIS: BENIGN NEOPLASM OF ISLETS OF LANGERHANS
TREATMENT: EXCISION OF TUMOR; MEDICAL MANAGEMENT

CODE: 950K
DIAGNOSIS: CANCER OF ENDOCRINE SYSTEM, EXCLUDING THYROID – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 952K
DIAGNOSIS: CANCER OF THYROID- TREATABLE; CARCINOID SYNDROME
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INLCUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 61K
DIAGNOSIS: CONGENITAL HYPOTHYROIDISM
TREATMENT: MEDICAL MANAGEMENT

CODE: 902K
DIAGNOSIS: DISORDERS OF:..ADRENAL SECRETION NOS
TREATMENT: MEDICAL MANAGEMENT; ADRENALECTOMY

CODE: 447K
DIAGNOSIS: DISORDERS OF PARATHYROID GLAND; BENIGN NEOPLASM OF PARATHYROID GLAND
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 904K
DIAGNOSIS: HYPER AND HYPOTHYROIDISM WITH LIFE-THREATENING COMPLICATIONS OR REQUIRING SURGERY
TREATMENT: MEDICAL MANAGEMENT; SURGERY

CODE: 31K
DIAGNOSIS: HYPOGLYCEMIC COMA; HYPERGLYCEMIA; DIABETIC KETOACIDOSIS
TREATMENT: MEDICAL MANAGEMENT

CODE: 236K
DIAGNOSIS: IRON DEFICIENCY; VITAMIN AND OTHER NUTRITIONAL DEFICIENCIES – LIFETHREATENING
TREATMENT: MEDICAL MANAGEMENT

CODE: 901K
DIAGNOSIS: LIFE-THREATENING CONGENITAL ABNORMALITIES OF CARBOHYDRATE, LIPID, PROTEIN AND AMINO ACID METABOLISM
TREATMENT: MEDICAL MANAGEMENT

CODE: 903K
DIAGNOSIS: LIFE-THREATENING DISORDERS OF FLUID AND ELECTROLYTE BALANCE, NOS
TREATMENT: MEDICAL MANAGEMENT

Urinary and Male Genital System

CODE: 354L
DIAGNOSIS: ABSCESS OF PROSTATE
TREATMENT: TURP; DRAIN ABSCESS

CODE: 904L
DIAGNOSIS: ACUTE AND CHRONIC PYELONEPHRITIS; RENAL & PERINEPHRIC ABSCESS
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 903L
DIAGNOSIS: ACUTE GLOMERULONEPHRITIS AND NEPHROTIC SYNDROME
TREATMENT: MEDICAL MANAGEMENT

CODE: 954L
DIAGNOSIS: CANCER OF PENIS AND OTHER MALE GENITAL ORGAN – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 953L
DIAGNOSIS: CANCER OF PROSTATE GLAND – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 950L
DIAGNOSIS: CANCER OF TESTIS – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 952L
DIAGNOSIS: CANCER OF URINARY SYSTEM INCLUDING KIDNEY AND BLADDER – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 906L
DIAGNOSIS: CONGENITAL ANOMALIES OF URINARY SYSTEM – SYMPTOMATIC AND LIFE-THREATENING
TREATMENT: NEPHRECTOMY/REPAIR

CODE: 901L
DIAGNOSIS: END STAGE RENAL DISEASE REGARDLESS OF CAUSE
TREATMENT: DIALYSIS & RENAL TRANSPLANT WHERE DEPARTMENT OF HEALTH CRITERIA ARE MET ONLY (SEE CRITERIA PUBLISHED IN GPS 004-9001)

CODE: 900L
DIAGNOSIS: HYPERPLAS1A OF THE PROSTATE, WITH ACUTE UR1NARY RETENTION OR OBSTRUCTIVE RENAL FAILURE
TREATMENT: TRANSURETHRAL RESECTION; MEDICAL MANAGEMENT

CODE: 905L
DIAGNOSIS: OBSTRUCTION OF THE UROGENITAL TRACT, REGARDLESS OF CAUSE
TREATMENT: CATHETERIZATION; SURGERY; ENDOSCOPIC REMOVAL OF OBSTRUCTING
AGENT: LITHOTRIPSY

CODE: 436L
DIAGNOSIS: TORSION OF TESTIS
TREATMENT: ORCHIDECTOMY; REPAIR

CODE: 43L
DIAGNOSIS: TRAUMA TO THE URINARY SYSTEM INCLUDING RUPTURED BLADDER
TREATMENT: CYSTORRHAPHY;SUTURE; REPAIR

CODE: 289L
DIAGNOSIS: URETERAL FISTULA (INTESTINAL)
TREATMENT: NEPHROSTOMY

CODE: 359L
DIAGNOSIS: VESICOURETERAL REFLUX
TREATMENT: MEDICAL MANAGEMENT; REPLANTATION

Female Reproductive System

CODE: 539M
DIAGNOSIS: ABSCESSES OF BARTHOLIN’S GLAND AND VULVA
TREATMENT: INCISION AND DRAINAGE; MEDICAL MANAGEMENT

CODE: 288M
DIAGNOSIS: ACUTE PELVIC INFLAMMATORY DISEASE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 954M
DIAGNOSIS: CANCER OF CERVIX – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY AND CHEMOTHERAPY

CODE: 952M
DIAGNOSIS: CANCER OF OVARY – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 950M
DIAGNOSIS: CANCER OF UTERUS – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 953M
DIAGNOSIS: CANCER OF VAGINA, VULVA AND OTHER FEMALE GENITAL ORGANS NOS – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY AND CHEMOTHERAPY

CODE: 960M
DIAGNOSIS: CERVICAL AND BREAST CANCER SCREENING
TREATMENT: CERVICAL SMEARS; PERIODIC BREAST EXAMINATION

CODE: 645M
DIAGNOSIS: CANCER OF CERVIX – TREATABLE
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY AND CHEMOTHERAPY

CODE: 266M
DIAGNOSIS: DYSPLASIA OF CERVIX AND CERVICAL CARCINOMA-IN-SITU; CERVICAL CONDYLOMATA
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 53M
DIAGNOSIS: ECTOPIC PREGNANCY
TREATMENT: SURGERY

CODE: 460M
DIAGNOSIS: FISTULA INVOLVING FEMALE GENITAL TRACT
TREATMENT: CLOSURE OF FISTULA

CODE: 951M
DIAGNOSIS: HYDATIDIFORM MOLE; CHORIOCARCINOMA
TREATMENT: D & C; HYSTERECTOMY; CHEMOTHERAPY

CODE: 902M
DIAGNOSIS: INFERTILITY
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 528M
DIAGNOSIS: MENOPAUSAL MANAGEMENT, ANOMALIES OF OVARIES, PRIMARY AND SECONDARY AMENORRHOEA, FEMALE SEX HORMONES ABNORMALITIES NOS, INCLUDING HIRSUTISM.
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT,INCLUDING HORMONE REPLACEMENT THERAPY

CODE: 4MM
DIAGNOSIS: NON-INFLAMMATORY DISORDERS AND BENIGN NEOPLASMS OF OVARY, FALLOPIAN TUBES AND UTERUS
TREATMENT: SALPINGECTOMY; OOPHORECTOMY; HYSTERECTOMY; MEDICAL AND SURGICAL MANAGEMENT

CODE: 237M
DIAGNOSIS: SEXUAL ABUSE, INCLUDING RAPE
TREATMENT: MEDICAL MANAGEMENT; PSYCHOTHERAPY

CODE: 903M
DIAGNOSIS: SPONTANEOUS ABORTION
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 435M
DIAGNOSIS: TORSION OF OVARY
TREATMENT: OOPHORECTOMY; OVARIAN CYSTECTOMY

CODE: 530M
DIAGNOSIS: UTERINE PROLAPSE; CYSTOCELE
TREATMENT: SURGICAL REPAIR

CODE: 296M
DIAGNOSIS: VOLUNTARY TERMINATION OF PREGNANCY
TREATMENT: INDUCED ABORTION; MEDICAL AND SURGICAL MANAGEMENT

Pregnancy and Childbirth

CODE: 67N
DIAGNOSIS: # LOW BIRTH WEIGHT (UNDER 1000g) WITH RESPIRATORY DIFFICULTIES
TREATMENT: # MEDICAL MANAGEMENT NOT INCLUDING VENTILATION

CODE: 967N
DIAGNOSIS: # LOW BIRTH WEIGHT (UNDER 2500 GRAMS &> 1000g) WITH RESPIRATORY DIFFICULTIES
TREATMENT: MEDICAL MANAGEMENT, INCLUDING VENTILATION; INTENSIVE CARE THERAPY

CODE: 71N
DIAGNOSIS: BIRTH TRAUMA FOR BABY
TREATMENT: MEDICAL MANAGEMENT; SURGERY

CODE: 901N
DIAGNOSIS: CONGENITAL SYSTEMIC INFECTIONS AFFECTING THE NEWBORN
TREATMENT: MEDICAL MANAGEMENT, VENTILATION

CODE: 904N
DIAGNOSIS: HAEMATOLOGICAL DISORDERS OF THE NEWBORN
TREATMENT: MEDICAL MANAGEMENT

CODE: 54N
DIAGNOSIS: NECROTIZ1NG ENTEROCOLITIS IN NEWBORN
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 74N
DIAGNOSIS: NEONATAL AND INFANT GIT ABNORMALITIES AND DISORDERS, INCLUDING MALROTATION AND ATRESIA
TREATMENT: MEDICAL AND SURGICAL MANAGEMENT

CODE: 902N
DIAGNOSIS: NEONATAL ENDOCRINE, METABLIC AND TOXIN-INDUCED CONDITIONS
TREATMENT: MEDICAL MANAGEMENT

CODE: 903N
DIAGNOSIS: NEUROLOGICAL ABNORMALITIES IN THE NEWBORN
TREATMENT: MEDICAL MANAGEMENT

CODE: 52N
DIAGNOSIS: PREGNANCY
TREATMENT: ANTENATAL AND OBSTETRIC CARE NECESSITATING HOSPITALISATION, INCLUDING DELIVERY

CODE: 56N
DIAGNOSIS: RESPIRATORY CONDITIONS OF NEWBORN
TREATMENT: MEDICAL MANAGEMENT; VENTILATION

Haematological, Infectious and Miscellaneous Systemic Conditions

CODE: 505
DIAGNOSIS: SYPHILIS – CQNGENITAL, SECONDARY AND TERTIARY
TREATMENT: MEDICAL MANAGEMENT

CODE: 168S
DIAGNOSIS: # HIV-INFECTION
TREATMENT: # HIV VOLUNTARY COUNSELLING AND TESTING CO-TRIMOXAZOLE AS PREVENTIVE THERAPY SCREENING AND PREVENTIVE THERAPY FOR TB.

DIAGNOSIS AND TREATMENT OF SEXUALLY TRANSMITTED INFECTIONS.

PAIN MANAGEMENT IN PALLIATIVE CARE.

TREATMENT OF COMMON OPPORTUNISTIC INFECTIONS.

PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV.

POST-EXPOSURE PROPHYLAXIS FOLLOWING SEXUAL ASSAULT.

MEDICAL MANAGEMENT AND MEDICATION, INCLUDING THE PROVISION OF ANTI-RETROVIRAL THERAPY, TO THE EXTENT THAT THIS IS PROVIDED FOR IN ESTABLISHED NATIONAL GUIDELINES APPLICABLE IN THE PUBLIC SECTOR (THE NATIONAL GUIDELINES ARE SET OUT IN THE OPERATIONAL PLAN FOR COMPREHENSIVE HIV AND AIDS CARE, MANAGEMENT AND TREATMENT FOR SOUTH AFRICA; AND THE NATIONAL ANTIRETROVIRAL TREATMENT GUIDELINES. BOTH DOCUMENTS ARE AVAILABLE AT THE OFFICE OF THE DIRECTOR-GENERAL: NATIONAL DEPARTMENT OF HEALTH).


CODE: 260S
DIAGNOSIS: # IMMINENT DEATH REGARDLESS OF DIAGNOSIS
TREATMENT: # COMFORT CARE; PAIN RELIEF; HYDRATION

CODE: 113S
DIAGNOSIS: ACQUIRED HAEMOLYT1C ANAEMIAS
TREATMENT: MEDICAL MANAGEMENT

CODE: 901S
DIAGNOSIS: MULTIPLE MYELOMA AND CHRONIC LEUKEMIAS
TREATMENT: TREATMENT: MEDICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 2778
DIAGNOSIS: ANAEROBIC INFECTIONS – LIFE THREATENING
TREATMENT: MEDICAL MANAGEMENT; HYPERBARIC OXYGEN

CODE: 488
DIAGNOSIS: ANAPHYLACTIC SHOCK
TREATMENT: MEDICAL MANAGEMENT; VENTILATION

CODE: 9008
DIAGNOSIS: APLASTIC ANEMIA; AGRANULOCYTOSIS; OTHER LIFE-THREATENING HERIDITARY IMMUNE DEFICIENCIES
TREATMENT: BONE MARROW TRANSPLANTATION; MEDICAL MANAGEMENT

CODE: 197S
DIAGNOSIS: BOTULISM
TREATMENT: MEDICAL MANAGEMENT

CODE: 338S
DIAGNOSIS: CHOLERA; RAT-BITE FEVER
TREATMENT: MEDICAL MANAGEMENT

CODE: 1968
DIAGNOSIS: CHRONIC GRANULOMATOUS DISEASE
TREATMENT: MEDICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY

CODE: 9168
DIAGNOSIS: COAGULATION DEFECTS
TREATMENT: MEDICAL MANAGEMENT

CODE: 2468
DIAGNOSIS: CYSTICERCOSIS; OTHER SYSTEMIC CESTODE INFECTION
TREATMENT: MEDICAL MANAGEMENT

CODE: 903S
DIAGNOSIS: DEEP-SEATED (EXCLUDING NAIL INFECTIONS), DISSEMINATED AND SYSTEMIC FUNGAL INFECTIONS
TREATMENT: MEDICAL MANAGEMENT; SURGERY

CODE: 44S
DIAGNOSIS: ERYSIPELAS
TREATMENT: MEDICAL MANAGEMENT

CODE: 179S
DIAGNOSIS: HEREDITARY ANGIOEDEMA; ANGIONEUROTIC ADEMA
TREATMENT: MEDICAL AND SURGICAL THERAPY

CODE: 174S
DIAGNOSIS: HEREDITARY HAEMOLYTIC ANAEMIAS (EG. SICKLE CELL); DYSERYTHROPOIETIC ANEMIA (CONGENITAL)
TREATMENT: MEDICAL MANAGEMENT

CODE: 201S
DIAGNOSIS: HERPETIC ENCEPHALITIS; REYE’S SYNDROME
TREATMENT: MEDICAL MANAGEMENT

CODE: 913S
DIAGNOSIS: IMMUNE COMPROMISE NOS AND ASSOCIATED LIFE-THREATENING INFECTIONS NOS
TREATMENT: MEDICAL MANAGEMENT

CODE: 9128
DIAGNOSIS: LEPROSY AND OTHER SYSTEMIC MYCOBACTERIAL INFECTIONS, EXCLUDING TUBERCULOSIS
TREATMENT: MEDICAL MANAGEMENT

CODE: 336S
DIAGNOSIS: LEPTOSPIROSIS; SPIROCHAETAL INFECTIONS NOS
TREATMENT: MEDICAL MANAGEMENT

CODE: 252S
DIAGNOSIS: LIFE-THREATENING ANAEMIA NOS
TREATMENT: MEDICAL MANAGEMENT; TRANSFUSION

CODE: 908S
DIAGNOSIS: LIFE-THREATENING CONDITIONS DUE TO EXPOSURE TO THE ELEMENTS, INCLUDING HYPO AND HYPERTHERMIA; LIGHTNING STRIKES]
TREATMENT: MEDICAL MANAGEMENT

CODE: 9078
DIAGNOSIS: LIFE-THREATENING RICKETTSIAL AND OTHER ARTHROPOD-BORNE DISEASES
TREATMENT: MEDICAL MANAGEMENT

CODE: 1728
DIAGNOSIS: MALARIA; TRYPANOSOMIASIS; OTHER LIFE-THREATENING PARASITIC DISEASE
TREATMENT: MEDICAL MANAGEMENT

CODE: 9048
DIAGNOSIS: METASTATIC INFECTIONS; SEPTICEMIA
TREATMENT: MEDICAL MANAGEMENT

CODE: 910S
DIAGNOSIS: MULTIPLE MYELOMA AND CHRONIC LEUKAEMIAS
TREATMENT: MEDICAL MANAGEMENT; WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY

CODE: 2478
DIAGNOSIS: POISONING BY INGESTION, INJECTION, AND NON-MEDICINAL AGENTS
TREATMENT: MEDICAL MANAGEMENT

CODE: 9118
DIAGNOSIS: SEXUALLY TRANSMITTED DISEASES WITH SYSTEMIC INVOLVEMENT NOT ELSWHERE SPECIFIED
TREATMENT: MEDICAL MANAGEMENT

CODE: 1288
DIAGNOSIS: TETANUS; ANTHRAX; WHIPPLES DISEASE
TREATMENT: MEDICAL MANAGEMENT

CODE: 122S
DIAGNOSIS: THALASSEMIA AND OTHER HEMOGLOBINOPATHIES – TREATABLE
TREATMENT: MEDICAL MANAGEMENT; BONE MARROW TRANSPLANT

CODE: 316S
DIAGNOSIS: TOXIC EFFECT OF GASES, FUMES, AND VAPORS
TREATMENT: MEDICAL THERAPY

CODE: 11S
DIAGNOSIS: TUBERCULOSIS
TREATMENT: DIAGNOSIS AND ACUTE MEDICAL MANAGEMENT; SUCCESSFUL TRANSFER TO MAINTENANCE THERAPY IN ACCORDANCE WITH DOH GUIDELINES

CODE: 937S
DIAGNOSIS: TUMOUR OF INTERNAL ORGAN (EXCLUDES SKIN): UNKNOWN WHETHER BENIGN OR MALIGNANT
TREATMENT: BIOPSY

CODE: 15S
DIAGNOSIS: WHOOPING COUGH, DIPTHERIA
TREATMENT: MEDICAL MANAGEMENT

Mental Illness

CODE: 182T
DIAGNOSIS: ABUSE OR DEPENDENCE ON PSYCHOACTIVE SUBSTANCE, INCLUDING ALCOHOL
TREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 WEEKS/YEAR

CODE: 901T
DIAGNOSIS: ACUTE DELUSIONAL MOOD, ANXIETY, PERSONALITY, PERCEPTION DISORDERS AND ORGANIC MENTAL DISORDER CAUSED BY DRUGS;
TREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 DAYS

CODE: 910T
DIAGNOSIS: ACUTE STRESS DISORDER ACCOMPANIED BY RECENT SIGNIFICANT TRAUMA, INCLUDING PHYSICAL OR SEXUAL ABUSE
TREATMENT: HOSPITAL ADMISSION FOR PSYCHOTHERAPY COUNSELLING UP TO 3 DAYS, OR UP TO 12 OUTPATIENT PSYCHOTHERAPY / COUNSELLING CONTACTS

CODE: 910T
DIAGNOSIS: ALCOHOL WITHDRAWAL DELIRIUM; ALCOHOL INTOXICATION DELIRIUM
TREATMENT: HOSPITAL BASED MANAGEMENT UP TO 3 DAYS LEADING TO REHABILITATION

CODE: 908T
DIAGNOSIS: ANOREXIA NERVOSA AND BULIMIA NERVOSA
TREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 WEEKS/YEAR OR MINIMUM OF 15 OUTPATIENT CONTACTS PER YEAR

CODE: 903T
DIAGNOSIS: ATTEMPTED SUICIDE, IRRESPECTIVE OF CAUSE
TREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 DAYS OR UP TO 6 OUTPATIENT CONTACTS

CODE: 184T
DIAGNOSIS: BRIEF REACTIVE PSYCHOSIS
TREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 WEEKS/YEAR

CODE: 910T
DIAGNOSIS: DELIRIUM: AMPHETAMINE, COCAINE, OR OTHER PSYCHOACTIVE SUBSTANCE
TREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 DAYS

CODE: 902T
DIAGNOSIS: MAJOR AFFECTIVE DISORDERS, INCLUDING UNIPOLAR AND BIPOLAR DEPRESSION
TREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 WEEKSLYEAR (INCLUDING INPATIENT ELECTRO-CONVULSIVE THERAPY AND INPATIENT PSYCHOTHERAPY) OR OUTPATIENT PSYCHOTHERAPY OF UP TO 15 CONTACTS

CODE: 907T
DIAGNOSIS: SCHIZOPHRENIC AND PARANOID DELUSIONAL DISORDERS
TREATMENT: HOSPITAL-BASED MEDICAL MANAGEMENT UP TO 3 WEEKS/YEAR

CODE: 909T
DIAGNOSIS: TREATABLE DEMENTIA
TREATMENT: ADMISSION FOR INITIAL DIAGNOSIS; MANAGEMENT OF ACUTE PSYCHOTIC SYMPTOMS – UP TO I WEEK

Explanatory notes and definitions to Annexure A

Interventions shall be deemed hospital-based where they require:

– An overnight stay in hospital.

 or

– The use of an operating theatre together with the administration of a general or regional anaesthetic.

 or

– The application of other diagnostic or surgical procedures that carry a significant risk of death, and consequently require on-site resuscitation and/or surgical facilities.

 or

– The use of equipment, medications or medical professionals not generally found outside of hospitals.

2)        Where the treatment component of a category in Annexure A is stated in general terms (i.e. “medical management” or “surgical management”, it should be interpreted as referring to prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition. Where significant differences exist between Public and Private sector practices, the interpretation of the Prescribed Minimum Benefits should follow the predominant Public Hospital practice, as outlined in the relevant provincial or national public hospital clinical protocols, where these exist. Where clinical protocols do not exist, disputes should be settled by consultation with provincial health authorities to ascertain prevailing practice. The following interventions shall however be excluded from the generic medical / surgical management categories unless otherwise specified:

i)          Tumour chemotherapy

ii)         Tumour radiotherapy

iii)        Bone marrow transplantation / rescue

iv)        Mechanical ventilation

v)         Hyperbaric oxygen therapy

vi)        Organ transplantation

vii)       Treatments, drugs or devices not yet registered by the relevant authority in the Republic of South Africa

2A)     In respect of treatments denoted as “medical management” or “surgical management,” note (2) above describes the standard of treatment required, namely “prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition.” Note (2) does not restrict the setting in which the relevant care should be provided, and should not be construed as preventing the delivery of any prescribed minimum benefit on an outpatient basis or in a setting other than a hospital, where this is clinically most appropriate.

3)        “Treatable” cancers. In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where:

i)          they involve only the organ of origin, and have not spread to adjacent organs

ii)         there is no evidence of distant metastatic spread

iii)        they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumour) or another vital organ

iv)        or, if points i. to iii. do not apply, there is a well demonstrated five year survival rate of greater than 10% for the given therapy for the condition concerned

4)        Tumour chemotherapy with or without bone marrow transplantation and other indications for bone marrow transplantation.

These are included in the prescribed minimum benefits package only where Annexure A explicitly mentions such interventions. Management may include a first full course of chemotherapy (including, if indicated, induction, consolidation and myeloablative components). Where specified in terms of Annexure A, this may be followed by bone marrow transplantation/rescue, according to tumour type and prevailing practice. The following conditions would also apply to the bone marrow transplantation component of the prescribed minimum benefits:

i)          the patient should be under 60 years of age

ii)         allogeneic bone marrow transplantation should only be considered where there is an HLA matched family donor

iii)        the patient should not have relapsed after a previous full course of chemotherapy

iv)        (points i. and ii. shall also apply to bone marrow transplantation for non-malignant diseases)

5)        Solid organ transplants. The prescribed minimum benefits Annexure includes solid organ transplants (liver, kidney and heart) only where these are provided by Public hospitals in accordance with Public sector protocols and subject to public sector waiting lists.

6)        In certain cases, specified categories shall take precedence over others present. Such “overriding” categories are preceded by the sign “#” in their descriptions within Annexure A. For éxample, where someone is suffering from pneumonia and HIV, because the HIV category (168S) is an overriding category, the entitlements guaranteed by the ‘pneumonia’ category (903D) are overridden.

7)        Hospital treatment where the diagnosis is uncertain and/or admission for diagnostic purposes. Urgent admission may be required where a diagnosis has not yet been made. Certain categories of prescribed minimum benefits are described in terms of presenting symptoms, rather than diagnosis, and in these cases, inclusion within the prescribed minimum benefits may be assumed without a definitive diagnosis. In other cases, clinical evidence should be regarded as sufficient where this suggests the existence of a diagnosis that is included within the package. Medical schemes may, however, require confirmatory evidence of this diagnosis within a reasonable period of time, and where they consistently encounter difficulties with particular providers or provider networks, such problems should be brought to the attention of the Council for Medical Schemes for resolution.

8)        NOS – not otherwise specified

9)        In respect of Code 902M (Diagnosis: Infertility), ‘medical and surgical management’ shall be limited to the following procedures or interventions :

a)        hysterosalpingogram

b)        the following blood tests:

i)          Day 3 FSH/LH

ii)         Oestradiol

iii)        Thyroid function (TSH)

iv)        Prolactin

v)         Rubella

vi)        HIV

vii)       VDRL

viii)      Chlamydia

ix)       Day 21 Progesterone

c)        laparoscopy

d)        hysteroscopy

e)        surgery (uterus and tubal)

f)          manipulation of ovulation defects and

g)        deficiencies

h)        semen analysis (volume; count; mobility;

i)          morphology; MAR-test)

j)          basic counseling and advice on sexual

k)        behaviour, temperature charts etc.

l)          treatment of local infections.

Chronic Conditions

DIAGNOSES:

·          Addison’s Disease

·          Asthma

·          Bipolar Mood Disorder

·          Bronchiectasis

·          Cardiac Failure

·          Cardiomyopathy

·          Chronic Renal Disease

·          Chronic Obstructive Pulmonary Disease

·          Coronary Artery Disease

·          Crohn’s Disease

·          Diabetes Insipidus

·          Diabetes Mellitus Types 1 & 2

·          Dysrhythrnias

·          Epilepsy

·          Glaucoma

·          Haemophilia

·          Hyperlipidaemia

·          Hypertension

·          Hypothyroidism

·          Multiple Sclerosis

·          Parkinson’s Disease

·          Rheumatoid Arthritis

·          Schizophrenia

·          Systemic Lupus Erythematosus

·          Ulcerative Colitis

TREATMENT:  DIAGNOSIS, MEDICAL MANAGEMENT AND MEDICATION, TO THE EXTENT THAT THIS IS PROVIDED FOR BY WAY OF A THERAPEUTIC ALGORITHM FOR THE SPECIFIED CONDITION, PUBLISHED BY THE MINISTER BY NOTICE IN THE GAZETTE.