Focus on hyperlipidaemia

What is hyperlipidaemia?

The term "lipid" refers to fats, which are substances that can be easily stored in the body and serve as a vital source of energy. Among the various types of lipids, cholesterol and triglycerides are the most notable. Hyperlipidaemia occurs when there is an excessive concentration of triglycerides or cholesterol in the bloodstream. This condition is significant because elevated lipid levels can substantially increase the risk of serious health issues, including heart attacks and strokes, which are among the leading causes of mortality worldwide.

Within the blood vessels, specifically the arteries, there can develop patches known as atheroma. These patches resemble small fatty lumps and are indicative of a condition known as atherosclerosis, which is also referred to as the hardening of the arteries. These atheroma patches are often described as plaques, and their presence is a critical factor in the development of cardiovascular diseases.

What is cholesterol?

Cholesterol is categorized into two main types based on the density of the lipoproteins that carry it in the bloodstream. Low-density lipoproteins (LDL) are often labeled as "bad cholesterol" because they are primarily responsible for the formation of atheroma, which is a key contributor to various cardiovascular diseases. Conversely, high-density lipoproteins (HDL) are known as "good cholesterol." HDL cholesterol plays a protective role, as it may help prevent the formation of atheroma by transporting cholesterol away from the arteries and back to the liver for excretion or recycling.

What are triglycerides?

Triglycerides represent the final product of the digestion and breakdown of fats found in the foods we consume. Whenever we eat, any food that is not immediately utilized for energy—whether it be carbohydrates, fats, or proteins—is converted into triglycerides. These triglycerides constitute the primary form of fat stored in the body. When considering body fat, such as that which accumulates on the hips or stomach, it is primarily in the form of triglycerides.

The signs and symptoms of hyperlipidaemia

In the early stages, hyperlipidaemia typically does not present any noticeable symptoms, making it a silent condition for many individuals. However, in rare cases, it can manifest with specific symptoms. These may include the appearance of yellowish nodules of fat, known as xanthomas, which can develop beneath the skin, particularly around the eyes, elbows, and knees, and even within tendons. Additionally, some individuals may experience an enlargement of the spleen and liver, or the development of whitish rings around the iris of the eye. Over time, persistently elevated cholesterol levels can lead to serious complications, including cardiovascular disease, which significantly increases the risk of heart attacks, strokes, and peripheral vascular disease.

Possible causes of hyperlipidaemia

The causes of hyperlipidaemia can be broadly classified into two categories: genetic and lifestyle-related. Familial or primary hyperlipidaemia is a genetic disorder that results in high cholesterol levels independent of dietary habits. On the other hand, secondary hyperlipidaemia is typically associated with poor dietary choices and other specific factors. Some common contributors to secondary hyperlipidaemia include excessive alcohol consumption, obesity, certain medications (like hormones or steroids), diabetes, kidney disease, an underactive thyroid gland, and even pregnancy. Each of these factors can disrupt the body's lipid metabolism, leading to elevated lipid levels in the blood.

How to register on the chronic programme

If you have been diagnosed with Addison’s disease, it is essential to take the necessary steps to ensure you receive appropriate care. You should ask your doctor to reach out to our Chronic Medicine Department by calling 0860 11 78 59 to register you in the Chronic Medicine Management Programme. A chronic medicine consultant will coordinate with your physician regarding your treatment plan. Once the diagnostic criteria are met and relevant blood results are submitted, your treatment will be reviewed and approved. We will inform you whether your treatment is covered under the Momentum Medical Scheme formulary or if you will be required to make a co-payment. Upon receiving 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 or facility—such as a doctor, pharmacist, or hospital—that is prioritized by the medical scheme for diagnosing, treating, or caring for members with Prescribed Minimum Benefit conditions. If you choose not to use the DSP and opt for a different healthcare provider, a co-payment may be applicable. It is also important to note that authorizations typically expire after 12 months. If there is no change in your prescribed medication, 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 treatment plan.

For further information regarding your chronic benefits and where to obtain chronic medications and treatments, click here.

Hospitalisation

In the event that you require hospitalization due to complications related to cardiac failure, it is crucial to take prompt action. You can log in to the Momentum App, utilize the web chat feature available on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message, or call us at 0860 11 78 59 to request pre-authorization for your hospital stay. Once your request is received, we will assign a case manager who will follow up with you regarding your hospitalization.

Treatment plan

Once you are successfully registered in the programme, you will gain access to a comprehensive treatment plan. This plan may encompass coverage for necessary medical tests, consultations with doctors, and other benefits deemed medically essential by your healthcare provider. Each aspect of your treatment plan will be carefully reviewed by our clinical team to ensure that it aligns with best practices and is appropriate for your specific needs.

Compliance

To ensure the effectiveness of your treatment, it is vital to adhere to the following guidelines: First, obtain your chronic medication on a monthly basis to maintain a consistent supply. Second, always take your medication according to the dosage and quantity prescribed by your healthcare provider. Lastly, it is crucial not to miss any doses, as this can have serious implications for your health and overall well-being. Adhering to these practices is essential for maintaining optimal health outcomes.

Please make sure 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 your claim under the Chronic Benefit. Proper coding is essential for the timely and correct payment of claims.

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 on consultations or tests.
• The treatment is not deemed clinically appropriate.

Contact us

If you have any questions or need assistance, you can reach out to us through the web chat feature available 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: The Momentum Medical Scheme collaborates with a network of designated service providers, including associated general practitioners (GPs) and specialists, as well as state facilities, to ensure that our members receive appropriate diagnosis and treatment for Prescribed Minimum Benefits.

A formulary: This is a comprehensive list of medications covered by your health plan, from which your doctor can prescribe the most suitable medication for your chronic condition.

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

Prescribed Minimum Benefits: This term encompasses a defined list of benefits that all medical schemes in South Africa must provide coverage for, as mandated by the Medical Schemes Act 131 of 1998 and its accompanying regulations. To access these benefits, certain criteria must be met: your medical condition must qualify for coverage and be included in the defined list of conditions, the required treatment must align with the treatments specified in the defined benefits, and you must utilize the Scheme’s Designated Service Providers. For more 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 only up to the Momentum Medical Scheme Rate, and relevant co-payments will apply. However, if non-designated service providers are used in emergencies, this is considered involuntary, and co-payments will be waived.