Focus on systemic lupus erythematous

What is systemic lupus erythematosus?

Lupus is an autoimmune disorder that is marked by both acute and chronic inflammation affecting various tissues throughout the body. Autoimmune diseases occur when the immune system mistakenly attacks the body's own tissues instead of targeting harmful invaders like bacteria and viruses. The immune system is a highly intricate network designed to defend against infections, and it employs antibodies as one of its primary weapons. These antibodies function like vigilant security guards, constantly on the lookout to protect the body from illnesses.

In individuals with lupus, the immune system produces abnormal antibodies that do not target foreign pathogens but instead attack the body’s own healthy tissues. These harmful antibodies are known as autoantibodies. The presence of these autoantibodies, along with inflammation-inducing cells, can affect tissues in various parts of the body. As a result, lupus has the potential to cause complications in numerous areas, including the skin, heart, lungs, kidneys, joints, and even the nervous system. When lupus manifests primarily on the skin, resulting in rash outbreaks, it is referred to as lupus dermatitis or cutaneous lupus erythematosus. A specific type of lupus dermatitis that is restricted to the skin without affecting internal organs is known as discoid lupus. Conversely, when the disease impacts internal organs, it is classified as systemic lupus erythematosus (SLE).

The signs and symptoms of systemic lupus erythematosus (SLE)

The symptoms of SLE can vary significantly from one individual to another and may appear sporadically. Almost all patients with SLE experience joint pain and swelling, with some developing arthritis as a result. The joints most commonly affected include those in the fingers, hands, wrists, and knees.

Other common symptoms include:

• Chest pain that occurs during deep breaths
• Fatigue that can be overwhelming
• Unexplained fever
• A general feeling of discomfort or malaise
• Hair loss, which can be distressing
• Ulcers in the mouth that can be painful
• Increased sensitivity to sunlight
• Skin rashes, particularly a distinctive "butterfly" rash that appears in about half of those with SLE, typically over the cheeks and across the bridge of the nose, but it can also spread and worsen with sun exposure
• Swollen lymph nodes

Additionally, symptoms can differ based on which specific bodily systems are affected:

• Brain and nervous system: Symptoms may include headaches, numbness, tingling sensations, seizures, vision problems, and changes in personality.
• Digestive tract: Individuals may experience abdominal pain, nausea, and vomiting.
• Heart: There may be irregular heart rhythms (arrhythmias).
• Lungs: Symptoms can include coughing up blood and experiencing difficulty in breathing.
• Skin: Patients might notice patchy skin color and a condition where fingers change color in response to cold (known as Raynaud phenomenon).
• Kidneys: Symptoms can manifest as swelling in the legs and unexpected weight gain.

It is worth noting that some individuals may only experience skin-related symptoms without any internal complications.

Possible causes of SLE

The precise causes behind autoimmune diseases like SLE remain largely unknown. However, it is observed that SLE is significantly more prevalent among women than men, and it can develop at any age. The disease is most frequently diagnosed in individuals between the ages of 10 and 50. In some cases, SLE may also be triggered by certain medications, including:

• Isoniazid
• Hydralazine
• Procainamide

How to register on the chronic programme

If you have received 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 in the Chronic Medicine Management Programme. A chronic medicine consultant will collaborate with your healthcare provider to discuss your treatment options. Once the necessary diagnostic criteria are met and blood test results are provided, the treatment plan will receive approval. You will be informed whether your treatment is included within the Momentum Medical Scheme formulary or if you will need to make a co-payment. After receiving authorization, you can present your prescription to your designated service provider to obtain your medication, and the claim can then be submitted. A designated service provider (DSP) is a healthcare professional, such as a doctor, pharmacist, or hospital, that is preferred by the medical scheme for diagnosing, treating, or caring for a condition that falls under the Prescribed Minimum Benefits. Should you choose not to use the DSP and opt for a different provider, a co-payment may apply. Authorization typically expires after 12 months. If there are no changes in your medication regimen, 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 more detailed information regarding your chronic benefits and where to obtain chronic medications and treatments, please click here.

Hospitalization

If hospitalization is necessary due to complications from cardiac failure, you can log in to the Momentum App, reach out to us via the web chat feature on momentummedicalscheme.co.za, send us an email at [e-mail], send a WhatsApp message, or call us at 0860 11 78 59 to request pre-authorization. A dedicated case manager will be assigned to follow up on your hospitalization.

Treatment plan

Once you are successfully registered in the program, you will gain access to a treatment plan that may include coverage for necessary tests, doctor visits, or other medically essential benefits as determined by your healthcare provider. These will be evaluated by our clinical team to ensure that they are appropriate for your condition.

Compliance

It is crucial for you to:

• Obtain your chronic medication on a monthly basis.
• Ensure that you take your medication according to the dosage and quantity prescribed by your healthcare provider.
• Make certain that you do not miss any doses, as this is vital not only for compliance but also for your overall health and well-being.

Please ensure your claims include the appropriate ICD-10 code

It is essential that all claims submitted contain the relevant ICD-10 codes (diagnostic codes) so that we can accurately identify and process the claim through the Chronic Benefit.

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

• The claims are submitted without the necessary ICD-10 codes.
• You have surpassed the frequency limits for consultations or tests.
• The treatment is deemed not clinically appropriate.

Contact us

You can reach out to us through the web chat feature on momentummedicalscheme.co.za, send an email to [e-mail], send 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 conditions that fall under the Prescribed Minimum Benefits.

A formulary refers to a list of medications that are covered under your plan, from which your doctor can prescribe suitable medications for your chronic condition.

ICD-10 is the coding system used for diagnoses.

Prescribed Minimum Benefits represent a 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 related regulations. To access these benefits:

• 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 more information on 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 reimburse benefits up to the Momentum Medical Scheme Rate, and applicable co-payments will apply. However, if you use non-designated service providers in the case of an emergency medical condition, it will be considered involuntary, and co-payments will be waived.