Focus on Crohn's disease

What is Crohn's disease?

Crohn's disease is classified as an inflammatory bowel disease (IBD), which is a term used to describe a group of conditions that cause chronic inflammation of the gastrointestinal tract. This disease specifically results in inflammation of the lining of the digestive tract, which can manifest as a variety of symptoms. Individuals suffering from Crohn's disease often experience significant abdominal pain, severe and persistent diarrhea, overwhelming fatigue, unintentional weight loss, and malnutrition due to the body's inability to properly absorb nutrients. The specific areas of the digestive tract that are affected can vary from person to person, and the inflammation can penetrate deeply into the layers of the affected bowel tissue. The condition can be extremely painful and debilitating, and in some cases, it may lead to serious, life-threatening complications if left untreated.

The signs and symptoms of Crohn's disease

• Diarrhea: Diarrhea is a prevalent issue for those living with Crohn's disease. The condition often leads to intensified intestinal cramping, which exacerbates the problem, resulting in loose stools that can be difficult to manage.
• Fever and fatigue: Many individuals with Crohn's disease report experiencing a low-grade fever, which may arise from inflammation or potential infection within the body. Alongside this, there is often a persistent feeling of tiredness or low energy that can significantly impact daily life.
• Abdominal pain and cramping: The inflammation and ulceration associated with Crohn's disease can disrupt the normal movement of food and waste through the digestive tract. This disruption may lead to varying levels of pain and cramping, ranging from mild discomfort to severe pain, which can be accompanied by nausea and vomiting.
• Blood in your stool: Some individuals may notice bright red blood in the toilet bowl or darker blood mixed with their stool. It is also possible to have bleeding that is not visible to the naked eye, known as occult blood.
• Mouth sores: Crohn's disease can lead to the development of painful ulcers in the mouth, which are similar to canker sores and can make eating and speaking uncomfortable.
• Reduced appetite and weight loss: The combination of abdominal pain, cramping, and the body's inflammatory response can significantly affect appetite and the ability to digest and absorb food, leading to noticeable weight loss.
• Perianal disease: Individuals may experience pain or drainage near the anus, which can occur as a result of inflammation leading to the formation of a fistula, a tunnel that develops into the skin.
• Other potential complications: In severe cases of Crohn's disease, other symptoms may arise, including inflammation of the skin, eyes, and joints, as well as inflammation of the liver or bile ducts. Additionally, children with severe Crohn's disease may experience delayed growth or sexual development.

Possible causes of Crohn's disease

The precise cause of Crohn's disease remains unknown; however, it is believed to be a condition that arises when the body's immune system mistakenly attacks and destroys healthy tissue in the digestive tract, classifying it as an autoimmune disorder. There are several factors that may contribute to the onset of Crohn's disease:

• Immune system response: It is possible that an infection caused by a virus or bacterium could trigger Crohn's disease. When the immune system attempts to combat these invading microorganisms, an abnormal immune response may occur, causing the immune system to also attack the cells within the digestive tract.
• Heredity: There is a noted correlation between Crohn's disease and family history, as it is more prevalent among individuals who have family members diagnosed with the condition. This suggests that genetic factors may play a role in increasing susceptibility to the disease. However, it is important to note that many individuals diagnosed with Crohn's disease do not have a family history of the condition.

When to see a doctor

• If you are experiencing persistent abdominal pain, it is advisable to seek medical attention.
• Noticing blood in your stool should prompt an immediate consultation with a healthcare provider.
• If you are dealing with ongoing episodes of diarrhea that do not improve with over-the-counter medications, it is essential to see a doctor.
• An unexplained fever lasting more than a couple of days warrants a medical evaluation.
• Unexplained weight loss can be a serious concern and should be discussed with a healthcare professional.

How to register on the chronic program

Upon receiving a diagnosis of Addison’s disease, it is important to ask your doctor to reach out to our Chronic Medicine Department at 0860 11 78 59 to initiate your registration on the Chronic Medicine Management Programme. A chronic medicine consultant will coordinate with your healthcare provider regarding your treatment plan. Once the necessary diagnostic criteria are met and relevant blood test results are submitted, your treatment will be approved. We will inform you whether your treatment is covered under the Momentum Medical Scheme formulary or if a co-payment will be required. After receiving authorization, you can present your prescription to your designated service provider to obtain your medication, and the necessary claim can be submitted. A designated service provider (DSP) refers to a healthcare provider, such as a doctor, pharmacist, or hospital, that the medical scheme recommends as the first choice for diagnosis, treatment, or care for a Prescribed Minimum Benefit condition. Should you choose not to use the DSP and opt for an alternative healthcare provider, a co-payment may apply. Typically, the authorization remains valid for 12 months. If there are no changes to the medication you require, your doctor or pharmacist can contact us at 0860 11 78 59 to renew the authorization. The same procedure applies if there are any modifications or additions to your authorization.

For additional information regarding your chronic benefits and where to obtain chronic medication and treatment, please click here.

Hospitalization

If hospitalization is necessary due to complications related to cardiac failure, please log in to the Momentum App or reach out to us through the web chat feature available on momentummedicalscheme.co.za. You can also email us at [e-mail], send us a WhatsApp message, or call us at 0860 11 78 59 to request pre-authorization. A case manager will be assigned to monitor your hospital stay and provide assistance.

Treatment plan

Once you have been registered on the program, you will gain access to a comprehensive treatment plan. This plan may encompass coverage for essential tests, consultations with doctors, and other benefits that are deemed medically necessary by your healthcare provider. All proposed treatments will be evaluated by our clinical team to ensure their appropriateness and effectiveness for your condition.

Compliance

It is crucial for your health that you adhere to the following compliance measures:

• Obtain your chronic medication on a monthly basis to ensure continuity of care.
• Take your medication exactly as prescribed by your healthcare provider, paying close attention to the dosage and quantity.
• Do not miss any doses, as this is vital not only for maintaining compliance but also for preventing serious health implications.

Please ensure your claims have the appropriate ICD-10 code

It is essential that all claims submitted include the correct ICD-10 codes (diagnostic codes). This ensures that we can accurately identify the claim and process it for payment under the Chronic Benefit.

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 frequency limit for consultations or tests.
• The treatment provided is not deemed clinically appropriate.

Contact us

If you need assistance, you can reach out to us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message, or call us at 0860 11 78 59.

Glossary of terms

Designated service providers: Momentum Medical Scheme utilizes a network of designated service providers, including associated general practitioners and specialists, as well as state facilities, depending on the circumstances, to diagnose and treat our members for the Prescribed Minimum Benefits.

A formulary: This is a list of medications that are covered under your specific medical plan, from which your doctor can prescribe the appropriate medication for your chronic condition.

ICD-10: This refers to the diagnosis code used for identifying medical conditions.

Prescribed Minimum Benefits: This is a mandated list of benefits that all medical schemes in South Africa must provide coverage for, as outlined in the Medical Schemes Act 131 of 1998 and its accompanying regulations. To access these benefits, the following criteria must be met:

• Your medical condition must qualify for coverage and be included in the defined list of Prescribed Minimum Benefit conditions.
• The treatment you require must align with the treatments specified in the defined benefits.
• You must utilize the Scheme’s Designated Service Providers. For further information 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 applicable co-payments will apply. However, if you require non-designated service providers in the case of an emergency medical condition, this is considered involuntary, and co-payments will be waived.