Diagnosed with Kidney Stones? Here's What to Do About Your Medical Aid

A kidney stone diagnosis — even a first episode — is a signal to take two actions immediately: get through the acute event with full scheme support, and plan to prevent the next one. This guide covers both.

The Honest Starting Point

Kidney stone treatment is a PMB condition — your scheme must fund acute management and stone removal procedures. What is NOT covered under PMB: recurrent stone prevention medication, dietary counselling, and metabolic workup. Those come from your day-to-day benefit.

The key financial risk with kidney stones is the specialist shortfall — a urologist performing ureteroscopy or PCNL in a private hospital will almost certainly charge above scheme rate. Without gap cover, that shortfall is yours.

Step 1: Get Through the Acute Event

If you are still in the acute phase (ER, hospital admission, or awaiting procedure):

Analgesia: IV NSAIDs (ketorolac) and opioids for acute colic are funded under the PMB. Oral NSAIDs (diclofenac, ibuprofen) for home management are day-to-day.

Tamsulosin for stone passage: If your urologist prescribes tamsulosin (alpha-blocker) to facilitate passage of a small ureteric stone, this is funded from your day-to-day benefit (ATB/MSA). Cost: R400–R800/month. Most prescriptions are short-term (2–4 weeks).

Imaging: CT KUB is the diagnostic gold standard and is funded as PMB. The scheme will authorise this in the acute setting. If you have a small stone that is expected to pass spontaneously, repeat ultrasound (not CT) is preferred for follow-up to limit radiation.

Step 2: Confirm Pre-Authorisation for Any Procedure

If your stone requires intervention (ESWL, ureteroscopy, or PCNL), pre-authorisation is required. Call your scheme and have your urologist's rooms call simultaneously:

What you need for pre-auth: - Your urologist's practice number and ICD-10 code (N20.0 — calculus of kidney; N20.1 — calculus of ureter; N20.9 — urinary calculus, unspecified) - Stone size and location (from CT KUB report) - Planned procedure name: ESWL / ureteroscopy with laser lithotripsy / PCNL - Proposed DSP hospital

Say: "I need pre-authorisation for [procedure] for a [Xmm stone at location] as an acute urological PMB event. Please confirm the procedure is approved, the DSP hospital, and the scheme tariff for the urologist."

JJ stent removal: If a JJ stent will be placed after ureteroscopy, get written confirmation that stent removal (cystoscopy) is included in the pre-authorisation or will be separately approved. Without this, you may face an unexpected bill for stent removal 2–4 weeks later.

Step 3: Notify Gap Cover Before Any In-Hospital Procedure

If you have gap cover: call your gap insurer before any in-hospital stone procedure.

Gap cover addresses the Out-of-Pocket Limit — the shortfall between what your medical aid pays and what your urologist and anaesthesiologist charge. For ureteroscopy or PCNL, this shortfall can be R10,000–R40,000.

Most gap cover policies require pre-notification before elective procedures. Even for urgent procedures, notify as soon as possible.

Step 4: If You Passed the Stone — Send It to Pathology

If you passed a stone spontaneously (or it was retrieved during ureteroscopy), send it to pathology for stone composition analysis. This is one of the most useful pieces of information for preventing recurrence:

Stone analysis is a pathology cost funded from day-to-day/ATB. Request it explicitly.

Step 5: Metabolic Workup — For Recurrent Formers

After a second stone, or for high-risk first-time formers (family history, young age, bilateral stones), request a 24-hour urine metabolic workup:

• 24-hour urine for calcium, oxalate, urate, citrate, phosphate, sodium, creatinine
• Serum calcium, uric acid, PTH (parathyroid hormone), creatinine

This workup identifies treatable metabolic abnormalities. It is funded from pathology benefit (24-hour urine) and day-to-day for blood tests. Ask your urologist or GP to order it.

Step 6: Prevention — Medication and Diet

All stone formers: - Fluid intake: target urine output of at least 2 litres/day — drink enough that your urine is pale yellow - Reduce sodium (high salt = hypercalciuria) - Reduce animal protein - Avoid crash diets (rapid weight loss increases oxalate)

Calcium oxalate stones: Eat enough dietary calcium (with meals) — this binds oxalate in the gut and reduces urinary oxalate. Avoid calcium supplements unless necessary. Reduce spinach, nuts, tea (high oxalate).

Uric acid stones: Alkalinise urine with potassium citrate (R300–R600/month; day-to-day). Treat hyperuricaemia with allopurinol if present (generic: R50–R150/month; day-to-day).

Dietitian referral: For complex recurrent stone disease, a dietitian referral is worthwhile. Typically 1–2 sessions funded under day-to-day. Day-to-day cost: R800–R1,500/session.

Step 7: Urological Follow-Up Plan

Kidney stone disease requires ongoing urological follow-up. Post-procedure:

• Stent removal follow-up (cystoscopy — 2–4 weeks after URS)
• Imaging at 3–6 months (ultrasound preferred for follow-up to reduce radiation)
• Annual kidney function monitoring (eGFR) — especially if you have multiple stone episodes or solitary kidney
• Metabolic workup if not done previously

All are day-to-day costs. Urologist consultation: R500–R1,500 depending on scheme tariff.

Key Calls to Make

Talk to Eldon

Kidney stone pre-authorisation for ESWL and ureteroscopy can be declined or downgraded when coding is incorrect. AURA ensures procedures are correctly coded and pre-authorised at full PMB rate, and verifies gap cover is in place.

Review your plan for urological coverage →