Wrong Procedural Codes submitted to Medical aid, therefore scans approved under wrong annual benefit as opposed to PMB

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

The matter concerns the procedural codes submitted for my 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 in relation to the condition). However, they have indicated that the procedural codes submitted by burger 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 we are now expected to cover, even though the PMB basket should fully cater for these scans.

The codes submitted by your team include:

70553 – MRI Brain Stem W/O & W/Dye

72142 – MRI Neck Spine W/Dye

51410 and 10430 – Others

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 (relapsing remitting) 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 prescribed minimum benefit category.

We have tried to explain this to you authorising specialist, however, we have had little success. I therefore ask that you please review this case as a matter of urgency and provide the medical aid with the correct procedural codes that are linked to the MS basket. Alternatively let us clearly know what the issue at hand is.

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