Focus on coronary artery disease

What is coronary artery disease?

Coronary artery disease, commonly referred to as heart disease, arises from the accumulation of plaque within the coronary arteries. This condition is medically known as atherosclerosis, and it can lead to significant blockages in these vital blood vessels. Initially, the coronary arteries are smooth and flexible, allowing for the easy flow of blood. However, over time, they can become narrow and stiff due to plaque build-up, which restricts the flow of blood to the heart. As a result, the heart may become deprived of the oxygen and essential nutrients it requires to function effectively, leading to serious health complications.

The signs and symptoms of coronary artery disease

The most prevalent symptom associated with coronary artery disease is angina, which manifests as chest pain. Angina can present itself in various forms, including feelings of heaviness, pressure, aching, burning, numbness, fullness, squeezing, or a painful sensation in the chest area. It is important to note that angina may sometimes be confused with indigestion or heartburn. While the discomfort is typically experienced in the chest, it can also radiate to other areas, including the left shoulder, arms, neck, back, or jaw.

In addition to angina, there are several other symptoms that may accompany coronary artery disease. These can include:

• Shortness of breath: Individuals may experience difficulty breathing, especially during physical activity.
• Palpitations: This refers to irregular heartbeats, which may feel like skipped beats or a "flip-flop" sensation in the chest.
• A faster heartbeat: Some may notice an increased heart rate, even at rest.
• Weakness or dizziness: Feelings of fatigue or lightheadedness can occur, which may be alarming.
• Nausea: Some individuals may experience gastrointestinal discomfort, including nausea.
• Sweating: Unexplained sweating, especially when not related to physical exertion, can be a concerning symptom.

Possible causes of coronary artery disease

Several factors can contribute to the development of coronary artery disease. Key causes include:

• Smoking: Tobacco use is a significant risk factor that can damage blood vessels and promote plaque formation.
• High levels of fats and cholesterol: Elevated levels of certain fats and cholesterol in the bloodstream can lead to plaque accumulation.
• High blood pressure: Hypertension can cause damage to the arteries, making them more susceptible to plaque build-up.
• High blood sugar: Conditions such as insulin resistance and diabetes can lead to increased sugar levels in the blood, further contributing to artery damage.
• Blood vessel inflammation: Inflammation in the blood vessels can also play a role in the development of plaque.
• Early plaque formation: Plaque can begin to form in childhood, and over time, it may harden or rupture. Hardened plaque narrows the coronary arteries, reducing the flow of oxygen-rich blood to the heart, which can lead to angina.

How to register on the chronic programme

If you have been diagnosed with Addison’s disease, it is important to take the necessary steps to ensure you are registered on the Chronic Medicine Management Programme. To do this, you should ask your doctor to reach out to our Chronic Medicine Department by calling 0860 11 78 59. The chronic medicine consultant will work closely with your healthcare provider to discuss your treatment options. Once the diagnostic criteria have been fulfilled and relevant blood results have been submitted, your treatment will be approved. We will inform you whether your treatment falls within the Momentum Medical Scheme formulary or if you will be required to make a co-payment. Once you receive authorization, you can present your prescription to your designated service provider to obtain your medication, and the claim can be processed accordingly.

A designated service provider (DSP) is a healthcare professional, such as a doctor, pharmacist, or hospital, that is preferred by the medical scheme for members seeking diagnosis, treatment, or care for a Prescribed Minimum Benefit condition. If you choose not to utilize the DSP and instead opt for a different healthcare provider, you may incur additional co-payments. It is also worth noting that authorizations typically expire after 12 months. If there are no changes in your prescribed medication, your doctor or pharmacist can contact us at 0860 11 78 59 to renew the authorization. The same procedure will apply in the event of any changes or additions to your treatment plan.

For further information regarding your chronic benefits and the process to obtain chronic medication and treatment, please click here.

Hospitalisation

In the event that you require hospitalization due to complications related to cardiac failure, you can easily initiate the process by logging into the Momentum App. Alternatively, you may reach out to us via the web chat feature on momentummedicalscheme.co.za, send us an email at [e-mail], send us a WhatsApp message, or call us directly at 0860 11 78 59 to request pre-authorization for your hospitalization. Upon receiving your request, we will assign a case manager who will follow up with you regarding your hospital stay to ensure all necessary arrangements are made.

Treatment plan

Once you are successfully registered on the Chronic Medicine Management Programme, you will gain access to a comprehensive treatment plan. This plan may encompass coverage for various tests, consultations with doctors, and other medically necessary benefits as determined by your healthcare provider. Our clinical team will conduct a thorough review of these benefits to ensure they are appropriate and aligned with your health needs.

Compliance

It is crucial that you adhere to several important guidelines to maintain your health. First, you should obtain your chronic medication on a monthly basis to ensure a continuous supply. Second, it is vital that you take your medication exactly as prescribed by your doctor, adhering to the recommended dosage and quantity. Lastly, you must make every effort not to miss a dose, as this is essential not only for your compliance but also for your overall health and well-being. Missing doses can lead to serious health consequences, so it is important to prioritize your medication regimen.

Please make sure your claims have the appropriate ICD-10 code

For all claims submitted, it is essential to include the correct ICD-10 codes, which are diagnostic codes that help us accurately identify and process the claim from the Chronic Benefit. This ensures that your claims are handled efficiently and appropriately.

We may pay claims from your Day-to-day Benefits if:

• The claims are submitted without the relevant ICD-10 codes.
• You have exceeded the allowable frequency limit for consultations or tests.
• The treatment provided is not deemed clinically appropriate.

Contact us

If you have any questions or require assistance, you can easily reach out to us through our web chat feature on momentummedicalscheme.co.za, send us an email at [e-mail], send us a WhatsApp message, or call us at 0860 11 78 59.

Glossary of terms

Designated service providers: The Momentum Medical Scheme collaborates with a network of designated service providers, which includes associated general practitioners and specialists, as well as state facilities. These providers are utilized to diagnose and treat our members for conditions that fall under the Prescribed Minimum Benefits.

A formulary: This refers to a comprehensive list of medications that are covered under your specific medical scheme option, from which your doctor can prescribe suitable medication for your chronic condition.

ICD-10: This is the diagnostic code used to classify medical diagnoses.

Prescribed Minimum Benefits: This term refers to a defined set of benefits that all medical schemes in South Africa are mandated to cover as per the Medical Schemes Act 131 of 1998 and its associated regulations. To qualify for these benefits, your medical condition must be included in the defined list of Prescribed Minimum Benefit conditions, the required treatment must correspond with the treatments outlined in the defined benefits, and you must utilize the Scheme’s Designated Service Providers. For further details regarding Designated Service Providers, please refer to the definition provided on page 2.

If you choose to use non-designated service providers voluntarily, the Scheme will cover benefits up to the Momentum Medical Scheme Rate, and relevant co-payments will apply. However, if you use non-designated service providers in emergency medical situations, this is considered an involuntary choice, and any co-payments will be waived.