The Medical Schemes Act, No. 131 of 1998, recognizes infertility as a PMB disease under the category Female Reproductive System and treatment guidelines are classified as:
- Code : 902M
- Diagnosis : Infertility
- Treatment : Medical and surgical management
Furthermore the Regulations in terms of the Medical Schemes Act make specific reference to Infertility in Annexure A.
It states that the following is the minimum that MUST be covered by your Medical Aid Scheme:
In respect of Code 902M (Diagnosis: Infertility), ‘medical and surgical management’ shall be limited to the following procedures or interventions:-
- Hysterosalpingogram
- The following blood tests:
- Day 3 FSH/LH
- Oestradiol
- Thyroid function (TSH)
- Prolactin
- Rubella
- HIV
- VDRL
- Chlamydia
- Day 21 Progesterone
- Laparoscopy
- Hysteroscopy
- Surgery (uterus and tubal)
- Manipulation of ovulation defects and deficiencies
- Semen Analysis (volume; count; mobility; morphology; MAR-test)
- Basic Counselling and advice on sexual behaviour, temperature charts etc.
- Treatment of local infections.
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E28.0 |
902M |
Estrogen excess |
Medical and surgical management |
Infertility (Explanatory Note 9 of Annexure A of Regulations) |
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E28.1 |
Androgen excess |
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E28.2 |
Polycystic ovarian syndrome |
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E28.3 |
Primary ovarian failure |
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E28.8 |
Other ovarian dysfunction |
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E28.9 |
Ovarian dysfunction, unspecified |
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E34.5 |
Androgen resistance syndrome |
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E89.4 |
Postprocedural ovarian failure |
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E89.5 |
Postprocedural testicular hypofunction |
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N46 |
Male infertility |
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N88.3 |
Incompetence of cervix uteri |
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N91.0 |
Primary amenorrhoea |
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N96 |
Habitual aborter |
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N97.0 |
Female infertility associated with anovulation |
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N97.1 |
Female infertility of tubal origin |
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N97.2 |
Female infertility of uterine origin |
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N97.3 |
Female infertility of cervical origin |
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N97.4 |
Female infertility associated with male factors |
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N97.8 |
Female infertility of other origin |
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N97.9 |
Female infertility, unspecified |
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Z31.4 |
Procreative investigation and testing |
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Z31.6 |
General counselling and advice on procreation |
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Click here to read the CMS circular on Infertility, which is a good summary from the CMS, on the member’s PMB entitlements: CMScript Infertility of 2010
PRINT OUT THIS PAGE TO GIVE TO YOUR MEDICAL PRACTITIONER, IF THEY BATTLING WITH THE ICD10 CODES.
Goeie dag.
Ek wil graag bevestig indien ek gediagnoseer is met Polycystic Ovaries E28.2 moet my medies, Bestmed dit as n PMB registreer.
Hi Jean-Marie. They need to pay for the diagnosis but, they unfortunately won’t cover any fertility treatment after diagnosis.
After reading through your website I realized I had an Hysterosalpingogram last year July and my medical aid Gems didn’t pay for it, I had to pay for it cash, can I dtil claim my money back course it seems like it falls under diagnostic procedure and how do I go about claiming my money back?
So they have to pay for Semen Analysis if you are trying to diagnose infertility? Bestmed says they will not do so and lists it as an exclusion.
Yes they have to pay if a diagnosis has not yet been made. Refer them to this list.