Focus on epilepsy

What is epilepsy?

Epilepsy is a neurological disorder characterized by recurrent seizures, which are sudden, uncontrolled bursts of electrical activity in the brain. This condition is often referred to as "seizure disorders" because it encompasses various types of seizures that can affect individuals differently. Seizures can manifest as episodes of altered brain function, leading to changes in a person's awareness, behavior, or physical movements. These episodes can range from brief lapses of attention to violent convulsions, depending on the nature of the seizure and the specific areas of the brain that are impacted.

The symptoms of epilepsy

The symptoms experienced by individuals with epilepsy can vary widely from one person to another. Some may experience mild symptoms, such as simple staring spells, which often go unnoticed, while others may endure more severe symptoms, including intense shaking and a complete loss of consciousness. The type of seizure a person experiences is typically determined by the region of the brain that is affected, as well as the underlying cause of the epilepsy. It is common for seizures to follow a similar pattern each time they occur. Additionally, some individuals may experience a phenomenon known as an aura prior to a seizure, which can manifest as unusual sensations such as tingling, the perception of nonexistent smells, or emotional shifts.

There are different types of seizures, namely:

• Absence (petit mal) seizure - This type of seizure is characterized by brief lapses in consciousness, often appearing as a person staring blankly for a few seconds.
• Generalized tonic-clonic (grand mal) seizure - This is a more severe type of seizure that involves a loss of consciousness and violent muscle contractions.
• Partial (focal) seizure - These seizures occur in a specific area of the brain and can cause a variety of symptoms, depending on the affected region.

Common causes of seizures by age in newborns:

• Brain malformations can lead to abnormal electrical activity in the brain, resulting in seizures.
• A lack of oxygen during birth may cause brain damage, which can trigger seizure activity.
• Low levels of essential nutrients, such as blood sugar, calcium, magnesium, or other electrolytes, can disrupt normal brain function and provoke seizures.
• Inborn errors of metabolism, which are genetic disorders affecting the body's ability to convert food into energy, can also lead to seizures.
• Intracranial hemorrhage, or bleeding within the brain, can occur during or shortly after birth and may result in seizures.
• Maternal drug use during pregnancy can affect fetal brain development and increase the risk of seizures in newborns.

Common causes of seizures by age in infants and children:

• Fever is a common trigger for febrile seizures, which typically occur in young children during episodes of high fever.
• Although rare, brain tumors can lead to seizure activity in infants and children.
• Various infections, such as meningitis or encephalitis, can cause inflammation of the brain and result in seizures.

Common causes of seizures by age in children and adults:

• Congenital conditions, including Down's syndrome, Angelman's syndrome, tuberous sclerosis, and neurofibromatosis, can predispose individuals to seizures.
• Genetic factors may play a significant role in the development of epilepsy, with certain inherited conditions increasing the likelihood of seizures.
• Progressive brain diseases, though rare, can lead to seizures as they cause ongoing damage to brain tissue.
• Head trauma, resulting from accidents or injuries, can also lead to the onset of seizures in both children and adults.

Common causes of seizures by age in seniors:

• Stroke is a leading cause of seizures in older adults, as it can cause damage to brain tissue.
• Alzheimer's disease and other forms of dementia can lead to changes in brain function that may trigger seizures.
• Trauma, whether from falls or other accidents, can result in brain injuries that increase the risk of seizures in seniors.

How to register on the chronic programme

If you have been diagnosed with Addison’s disease, it is essential to take the next step by asking your doctor to reach out to our Chronic Medicine Department at 0860 11 78 59. This will initiate your registration on the Chronic Medicine Management Programme. Once your doctor contacts us, a chronic medicine consultant will work closely with them to develop your treatment plan. After the necessary diagnostic criteria are met and blood test results are submitted, we will review and approve your treatment regimen. We will inform you whether your prescribed treatment is included within the Momentum Medical Scheme formulary or if you will be required to make a co-payment. Upon receiving authorization, you can present your prescription at your designated service provider to obtain your medication, and the claim will be processed accordingly. A designated service provider (DSP) refers to a healthcare professional or facility that is prioritized by the medical scheme for the diagnosis, treatment, or care of a Prescribed Minimum Benefit condition. If you opt not to use the DSP and choose a different healthcare provider, a co-payment may apply. Typically, the authorization will expire after 12 months. If there are no changes in your medication, your doctor or pharmacist can contact us at 0860 11 78 59 to renew the authorization. This same procedure will be followed if there are any modifications or additions to your treatment plan.

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

Hospitalisation

In the event that you require hospitalization due to complications from cardiac failure, it is crucial to initiate the pre-authorization process. You can do this by logging into the Momentum App, utilizing the web chat feature available on momentummedicalscheme.co.za, sending us an email at [e-mail], messaging us on WhatsApp, or calling 0860 11 78 59. Once your request is received, we will assign a case manager to monitor and follow up on your hospital stay.

Treatment plan

Once you are successfully registered on the program, you will gain access to a comprehensive treatment plan. This plan may encompass coverage for various medical necessities, including diagnostic tests, consultations with healthcare providers, and other benefits deemed medically essential by your doctor. All proposed treatments will be evaluated by our clinical team to ensure their appropriateness and alignment with your health needs.

Compliance

It is vital that you adhere to the following guidelines to ensure your health and treatment progress: you should obtain your chronic medication on a monthly basis, meticulously follow the prescribed dosage and quantity as directed by your doctor, and avoid missing any doses. Adhering to these guidelines is not only crucial for your compliance with the treatment plan but also has significant implications for your overall health and well-being.

Please ensure your claims have the appropriate ICD-10 code

For all claims submitted, it is imperative that they include the correct ICD-10 codes, which are diagnostic codes. This ensures that we can accurately identify and process the claim 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 deemed clinically inappropriate.

Contact us

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

Glossary of terms

Designated service providers: Momentum Medical Scheme collaborates with a network of designated service providers, which includes associated general practitioners and specialists, as well as state facilities, to ensure that our members receive proper diagnosis and treatment for Prescribed Minimum Benefits.

A formulary refers to a comprehensive list of medications that are covered under your specific plan, which enables your doctor to prescribe the most suitable medication for your chronic condition.

ICD-10 stands for the International Classification of Diseases, 10th Revision, which is the coding system used for diagnoses.

Prescribed Minimum Benefits represent a set of healthcare services that all medical schemes in South Africa are mandated to cover according to the Medical Schemes Act 131 of 1998 and its 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 necessary treatment must align with the treatments specified in the defined benefits; and you must utilize the Scheme’s Designated Service Providers. For further details on Designated Service Providers, please refer to the definition provided on page 2.

If you voluntarily opt to use non-designated service providers, the Scheme will reimburse benefits up to the Momentum Medical Scheme Rate, and relevant co-payments will apply. In cases of emergency medical conditions where non-designated service providers are used, this is considered involuntary, and co-payments will be waived.