Discovery says CMS ruling doesn’t change its PMB policy

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Discovery Health has responded to a Council for Medical Schemes’ ruling that Discovery must fund an alternative surgical treatment for glaucoma, which Discovery had argued did not meet “PMB-level of care” treatment prerequisites.

Fin24 reports that Discovery Health CEO Dr Ryan Noach Noach said the scheme’s refusal was not about cost-cutting – it was about reliance on evidence-based care, something it would continue doing. Discovery says its Prescribed Minimum Benefits (PMB) policy remains centred around funding treatments where there is strong clinical evidence showing their effectiveness, even if they are more expensive than alternatives.

Fin24 reports that commenting on the ruling, Noach said the scheme encourages doctors to submit published clinical evidence as motivation if its their patients required alternative and new treatments. But it will fund those only if information submitted is in accordance with principles of “evidence-based-medicine”.

“It is important to note that the appeal board ruling was based on the exceptional circumstances as they apply to the member concerned. In our view, this ruling therefore does not create a precedent for changing how the PMB guidelines are applied,” Noach is quoted in the report as saying.

Full Fin24 report

See also

CMS’ precedent setting ruling against Discovery’s ‘irrational decision-making’

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