CMScript 6 of 2023: Focus on Ovarian Cysts

An ovarian cyst is a sac filled with fluid or semisolid material that forms within one or both ovaries. “Ovarian cysts” are included in PMB regulations and medical schemes must pay in full for the diagnosis, treatment and care for Non-inflammatory disorders and benign neoplasms of ovary, fallopian tubes and uterus, if the services were obtained from a DSP.

The prevalence of ovarian cysts is unclear as most cysts are not symptomatic, do not get treated and resolve without treatment.  In 2020, it was estimated that almost 7% of women in the world developed an ovarian cyst at some point in their lives.

“Ovarian cysts” are included in PMB regulations under Diagnosis and Treatment Pair (DTP) code 434M. This DTP refers to “Non-inflammatory disorders and benign neoplasms of ovary, fallopian tubes and uterus”. The Treatment component specified for this DTP is “Salpingectomy; oophorectomy; hysterectomy; medical and surgical management”. The medical schemes must pay for the diagnosis, treatment, and follow-up consultations and treatment in full if the services were obtained from a designated service provider (DSP). In case of an emergency, healthcare services must be paid in full, even if a non-DSP was used. The healthcare practitioner must assist the member in completing the forms to register for PMB benefits which must be funded by the medical scheme from the risk-benefit. Funding of PMB claims from the Medical Savings Account (MSA) contravenes the Medical Schemes Act. The medical schemes must flag possible PMB diagnoses for correct payment from the risk-benefit.

Download the CMScript here