Breast Cancer: What is covered as PMB level of care?

In 2020, breast cancer was the leading cause of new cases of cancer in the world with 2.26 million cases reported annually. South Africa also showed a similar trend with 14.3% of new cases of cancer in both men and women of all ages being attributed to breast cancer, putting it as the leading cause of new cancers reported.

Treatable breast cancer is included in the Prescribed Minimum Benefits (PMB) regulations under DTP 950J. Treatable cancers are defined in the PMB regulations as solid organ malignant tumours where:

  1. they involve only the organ of origin, and have not spread to adjacent organs
  2. there is no evidence of distant metastatic spread
  3. 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
  4. or, if points 1to 3 do not apply, there is a well demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned.

Regardless of which benefit option a member or beneficiary is on, the medical scheme must pay for the diagnosis, treatment, and care costs of treatable breast cancer. Screening through a physical breast examination, consultations with doctors and other health professionals, surgery, radiology, pathology, chemotherapy, and radiation therapy and breast reconstruction are included in what the medical scheme must cover.

Preventative or prophylactic mastectomy for the undiseased breast is PMB level of care for women who have breast cancer in only one breast. The reconstruction of the undiseased breast is also PMB level of care.

Trastuzumab is a biologic medication that is PMB level of care if certain clinical criteria is met.

Referral to genetic services is PMB level of care for women who are being investigated for breast cancer and have a family history that meets criteria for referral.

The following are not included in the PMB regulations and medical schemes can fund at their own discretion:

  • Preventative or prophylactic mastectomy in women who do not have any breast cancer.
  • Screening mammograms – most schemes will cover one mammogram a year on certain benefit options. It is important to find out if your medical scheme will cover the mammogram as screening before you go
  • Some biologics – some schemes will pay based on strict clinical guidelines and the benefit option the member belongs to. If the cancer has spread, only treatment that does not provide a five-year survival benefit of more than 10% is not PMB level of care. In such instances, clinically appropriate healthcare services must be funded.

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