PMBs aren’t automatic for every case of substance dependence. Your scheme will consider rehab a PMB when the presenting problem meets the PMB clinical entry criteria — usually an acute, clinically significant condition that fits an approved diagnosis-treatment pair and cannot safely be delayed. In practice that means clear evidence of medical or psychiatric risk (severe withdrawal, suicidal ideation, psychosis, acute intoxication) supported by objective assessment, correct ICD/DSM coding (substance-related codes such as ICD-10 F10–F19 where appropriate), and a treatment plan that matches PMB-listed protocols. If the condition is chronic dependence without imminent medical risk, it’s more likely to be considered under your discretionary or day-to-day benefits rather than PMB. Check whether your scheme uses Designated Service Providers (DSPs) for mental-health PMBs — using a DSP often smooths approval but doesn’t change the underlying clinical criteria.

Medical aids are clinical gatekeepers; they want a detailed, forensic file, not general statements of "needs help." Submit a current psychiatric assessment or psychiatrist/psychologist report with a clear DSM/ICD diagnosis, a withdrawal risk score (CIWA for alcohol, a documented plan for expected withdrawal management), substance use history, relevant bloodwork and toxicology if available, physical exam findings, comorbid medical and mental-health diagnoses, previous treatment attempts, and a day‑by‑day treatment plan with proposed length of stay and goals. Include medication plans (detox meds, relapse‑prevention meds), cost estimate by tariff code, and contact details for the admitting clinician. If you want the scheme to consider PMB status, the referring clinician must explicitly address the PMB criteria in the motivation. A hand‑written note or vague referral won’t cut it; the stronger and more specific the clinical justification, the higher the chance of approval.

Schemes split benefits: acute medical care (detox) sits under hospital or emergency benefits and often meets PMB criteria; ongoing psychosocial therapy and longer residential programmes frequently fall under chronic or day‑to‑day benefits, which have sub‑limits, annual caps, or exclusions. Many schemes also have networks (DSPs) where full cover applies, and when you use an out‑of‑network provider you can face tariff gaps or co‑payments. The practical upshot: detox may be authorised but the scheme will limit the number of residential "bed days" it pays for, require a step‑down to outpatient therapy, or apply an annual financial cap. You can push back: ask for a line‑by‑line breakdown of benefits, request clinical justification for any proposed step‑down, and provide ongoing clinical reports to support extensions. If the scheme cites tariffs, demand an itemised account and be ready to negotiate or escalate with additional specialist input.

Act fast. First, get a detailed written reason for the decline and the scheme’s appeal timeframe. Immediately request a contemporaneous, more comprehensive clinical motivation from the treating psychiatrist or specialist that addresses the scheme’s stated reasons and PMB criteria where relevant. If possible obtain an independent specialist report that corroborates risk and necessity. Lodge a formal appeal with the scheme and supply all supporting documentation in one packet. If the admission is urgent, document why waiting would pose serious risk and seek retrospective authorisation only as a last resort — schemes rarely cover non‑authorised admissions unless the emergency is clear. If the appeal fails and you suspect an incorrect application of PMB rules or unfair discrimination, escalate to the Council for Medical Schemes with your clinical evidence and correspondence; many successful reversals happen at that stage when PMB entitlement was wrongly denied.

Medical schemes respond to a member’s account and consent. If the patient is the scheme member, they must consent to share clinical details with family unless they’ve legally authorised another person. For minors or members who lack capacity, parents or legal guardians can act and sign authorisation paperwork. Be aware of POPIA: schemes will only disclose clinical details to authorised persons. Families often need to be pragmatic — the scheme will ask for the member’s signed consent, an admitting clinician’s report, and sometimes a power of attorney or affidavit if the member cannot sign. If the member refuses to authorise information sharing but needs urgent care, clinicians can still treat the emergency, but gaining scheme cover without consent will be harder. If the family is footing the bill, get a written funding undertakings and keep receipts; you can submit them later for reimbursement if the scheme approves retrospectively or grants a partial cover on appeal.