Specialised procedure and treatment
This document provides a guideline of the procedures and treatment covered on the various benefit options and paid from the Major Medical Benefit, irrespective of whether the procedure and treatment is performed in- or out-of-hospital.
Pre-authorisation is required regardless of where the procedure and treatment is performed. It is important to note that this is not the complete list of all procedures and treatment covered by the Scheme. Should you need clarity on whether a procedure and treatment is covered, please contact us to confirm.
| Ingwe | Evolve | Custom | Incentive | Extender | Summit | |
| Cardiovascular | ||||||
| 24-hour Holter ECG | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Blood transfusions | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Carotid angiograms | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Coronary angiogram | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Coronary angioplasty | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Plasmapheresis | ✔ | ✔ | ✔ | ✔ | ✔ | |
| ENT | ||||||
| Antroscopies | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Direct laryngoscopy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Grommets | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Myringotomy | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Nasal cautery | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Nasal scans and surgery | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Functional nasal and sinus surgery | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Tonsillectomy | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| General procedures and treatments | ||||||
| Biopsy of breast lump | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Drainage of subcutaneous abscess | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Removal of extensive skin lesions | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Removal of minor skin lesions | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Laparoscopy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Lymph node biopsy | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Nail surgery | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Open hernia repairs | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Superficial foreign body removal | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Treatment of headache | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Ingwe | Evolve | Custom | Incentive | Extender | Summit | |
| Gastro-intestinal | ||||||
| Colonoscopy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| ERCP | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Gastroscopies | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Oesophagoscopy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Sigmoidoscopy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Gynaecology | ||||||
| Cervical laser ablation | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Colposcopy | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Cone biopsy | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Dilatation & curettage | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Hysteroscopy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Incision and drainage of Bartholin’s cyst | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Marsupialisation of Bartholin’s cyst | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Tubal ligation | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Neurology | ||||||
| 48-hour Holter EEG | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Electro-convulsive therapy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Hyperbaric oxygen treatment for decompression sickness | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Myelogram | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Obstetrics | ||||||
| Amniocentesis | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Childbirth in non-hospital | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Ingwe | Evolve | Custom | Incentive | Extender | Summit | |
| Oncology | ||||||
| Chemotherapy (On Ingwe Option, limited to Prescribed Minimum Benefits at State facilities) | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Hyperbaric oxygen for radiation necrosis | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Radiotherapy (On Ingwe Option, limited to Prescribed Minimum Benefits at State facilities) | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Ophthalmology | ||||||
| Cataract removal | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Meibomian cyst excision | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Pterygium removal | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Trabeculectomy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Treatment of diseases of the conjunctiva | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Orthopaedic | ||||||
| Arthroscopy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Back and neck surgery (On Evolve Option, limited to Prescribed Minimum Benefits at State facilities) | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Bunionectomy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Carpal tunnel release | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Conservative back and neck treatment (On Evolve Option, covered at State facilities) | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Ganglion surgery | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Joint replacements (On Evolve Option, limited to Prescribed Minimum Benefits at State facilities) | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Ingwe | Evolve | Custom | Incentive | Extender | Summit | |
| Renal | ||||||
| Dialysis (On Ingwe and Evolve Options, limited to Prescribed Minimum Benefits at State facilities) | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Respiratory | ||||||
| Bronchography | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Bronchoscopy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Treatment of adult influenza | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Treatment of adult respiratory tract infections | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Urology | ||||||
| Cystoscopy | ✔ | ✔ | ✔ | ✔ | ✔ | |
| Prostate biopsy | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Vasectomy | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Anorectal procedures | ||||||
| Procedure for haemorrhoids, fissure and fistula | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
| Incision and drainage of abscess and/or cyst | ||||||
| Skin (deep/non-superficial lesions), subcutaneous tissue and pilonidal | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ |
- The costs of anaesthetists for gastroscopies and colonoscopies are covered up to R590 on Evolve and Custom, up to R1 230 on Incentive and Extender, and up to R1 460 on Summit (subject to pre-authorisation). For all other procedures, the costs of anaesthetists (if any) are covered if clinically appropriate.
- The specialised procedures and treatments listed attract a co-payment of R1 830 per authorisation on the Evolve and Custom Options. This co-payment may vary for some of the procedures, as illustrated below.
- Some of the specialised procedures and treatment listed could attract a co-payment on the Incentive and Extender Options, as illustrated below.
Specialised procedures and treatment co-payments
| How specialised procedures and treatment are covered on the Evolve Option | |
| The standard Evolve Option co-payment of R1 830 per authorisation applies to these procedures and treatments regardless of where they are performed Plus the specialised procedures co-payment of R3 660 per authorisation applies if performed in an acute or day hospital. | |
| Arthroscopies, Back and neck surgery*, Carpal tunnel release, Functional nasal and sinus procedures, Joint replacements*, Laparoscopies | Performed in a day hospital or acute hospital, subject to the relevant co-payment listed above |
| Gastroscopes, Colonoscopies, Cystoscopies, Sigmoidoscopies, Nail surgery, removing of extensive skin lesions | Performed out of hospital, in a day hospital or in an acute hospital, subject to the relevant co-payment listed above |
| Conservative back and neck treatment*, removal of minor skin lesions, Treatment of diseases of the conjunctiva, Treatment of headache, Treatment of adult influenza, Treatment of adult respiratory tract infections. | Low severity cases are not covered by the Scheme but can be paid from HealthSaver+, if available
High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above |
View the list of day hospitals on the Momentum app or momentummedicalscheme.co.za.
+ HealthSaver is an complementary product offered by Momentum.
* Covered at State facilities
| How specialised procedures and treatment are covered on the Custom Option | |
| The standard Custom Option co-payment of R1 830 per authorisation applies to these procedures and treatments regardless of where they are performed Plus the specialised procedures co-payment of R1 830 per authorisation applies if performed in a day hospital, or R3 840 per authorisation if performed in an acute hospital (hospital where overnight admissions apply) | |
| Arthroscopies, Back and neck surgery, Carpal tunnel release, Functional nasal and sinus procedures, Joint replacements, Laparoscopies | Performed in a day hospital or acute hospital, subject to the relevant co-payment listed above |
| Gastroscopes, Colonoscopies, Cystoscopies, Sigmoidoscopies, Nail surgery, removing of extensive skin lesions | Performed out of hospital, in a day hospital or in an acute hospital, subject to the relevant co-payment listed above |
| Conservative back and neck treatment, removal of minor skin lesions, Treatment of diseases of the conjunctiva, Treatment of headache, Treatment of adult influenza, Treatment of adult respiratory tract infections. | Low severity cases are not covered by the Scheme but can be paid from HealthSaver+, if available
High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above |
View the list of day hospitals on the Momentum app or momentummedicalscheme.co.za.
+ HealthSaver is an complementary product offered by Momentum.
| How specialised procedures and treatment are covered on the Incentive and Extender Options | |
| A co-payment of R1 830 per authorisation applies to these procedures and treatments if performed in a day hospital
Or a co-payment of R3 660 per authorisation applies to these procedures and treatments if performed in an acute hospital (hospital where overnight admissions apply) | |
| Arthroscopies, Back and neck surgery, Carpal tunnel release, Functional nasal and sinus procedures, Joint replacements, Laparoscopies | Performed in a day hospital or acute hospital, subject to the relevant co-payment listed above |
| Gastroscopes, Colonoscopies, Cystoscopies, Sigmoidoscopies, Nail surgery, removing of extensive skin lesions | Performed out of hospital, in a day hospital or in an acute hospital, subject to the relevant co-payment listed above |
| Conservative back and neck treatment, removal of minor skin lesions, Treatment of diseases of the conjunctiva, Treatment of headache, Treatment of adult influenza, Treatment of adult respiratory tract infections. | Low severity cases are not covered by the Scheme but can be paid from Day-to-day Benefits or HealthSaver+, if available
High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above |
View the list of day hospitals here or on the Momentum app.
+ HealthSaver is an complementary product offered by Momentum.