Description
Lupus is an autoimmune disease characterised by acute and chronic inflammation of various tissues of the body. Autoimmune diseases are illnesses that occur when the body's tissues are attacked by its own immune system. The immune system is a complex system within the body that is designed to fight infectious agents, such as bacteria and other foreign microbes. One of the ways that the immune system fights infections is by producing antibodies. They are like fighters or security guards protecting you from illness.
People with lupus produce abnormal antibodies; these antibodies attack the normal body tissues, instead of bacteria and viruses. These antibodies are referred to as autoantibodies. These antibodies and accompanying cells of inflammation can affect tissues anywhere in the body, so lupus has the potential to affect a variety of areas. Sometimes lupus can cause disease of the skin, heart, lungs, kidneys, joints or nervous system. When only the skin is involved (with rash outbreaks), the condition is called lupus dermatitis or cutaneous lupus erythematous. One form of lupus dermatitis that can be isolated to the skin, without internal disease, is called discoid lupus. When internal organs are involved, the condition is referred to as systemic lupus erythematous.
The signs and symptoms of systemic lupus erythematous (SLE)
Symptoms vary from person to person and may come and go. Almost everyone with SLE has joint pain and swelling. Some develop arthritis. The joints of the fingers, hands, wrists and knees are often affected.
Other common symptoms include:
- Chest pain when taking a deep breath
- Fatigue
- Fever with no other cause
- General discomfort, uneasiness, or ill feeling (malaise)
- Hair loss
- Mouth sores
- Sensitivity to sunlight
- Skin rash. A "butterfly" rash develops in about half people with SLE. The rash is most often seen over the cheeks and bridge of the nose, but can be widespread and gets worse in sunlight
- Swollen lymph nodes
Other symptoms depend on which part of the body is affected:
- Brain and nervous system: headaches, numbness, tingling, seizures, vision problems, personality changes
- Digestive tract: abdominal pain, nausea and vomiting
- Heart: abnormal heart rhythms (arrhythmias)
- Lung: coughing up blood and difficulty breathing
- Skin: patchy skin colour, fingers that change colour when cold (Raynaud phenomenon)
- Kidney: swelling in the legs, weight gain
Some people only have skin symptoms.
Possible causes of SLE
The underlying cause of autoimmune diseases is not fully known. SLE is much more common in women than men. It may occur at any age, but appears most often in people between the ages of 10 and 50. SLE may also be caused by certain drugs:
- Isoniazid
- Hydralazine
- Procainamide
How to register on the chronic programme
Once you have been diagnosed, please ask your doctor to contact our Chronic Medicine Department on 0860 11 78 59 to register you on the Chronic Medicine Management Programme.
The chronic medicine consultant will liaise with your doctor regarding your treatment. Once the diagnostic criteria have been met and x-rays (if applicable) and blood results have been submitted, the treatment will be approved. We will let you know whether the treatment falls within the Momentum Medical Scheme formulary or if you will need to pay a co-payment.
Once you receive authorisation, you can take your prescription to your designated service provider to get your medication and the claim can be submitted. A designated service provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is a medical scheme’s first choice when its members require diagnosis, treatment or care for a Prescribed Minimum Benefit condition. If you voluntarily choose not to use the DSP and choose to rather use a different hospital, doctor or pharmacy, we may charge a co-payment.
The authorisation usually expires after 12 months. If there is no change in the medicine you need to take, your doctor or pharmacist can contact us on 0860 11 78 59 to renew the authorisation. The same process applies when there are any changes or additions to your authorisation.
For more on your chronic benefits and where to obtain chronic medicine and treatment, click here.
Hospitalisation
If you need to be hospitalised for complications related to your illness, log in to the Momentum App, contact us via the web chat facility on momentummedicalscheme.co.za, email us at [email protected], send us a WhatsApp message or call us on 0860 11 78 59 to request pre-authorisation. We will allocate a case manager to follow up regarding your hospital stay.
Treatment plan
Once you are registered on the programme, you will have access to a treatment plan, which may include cover for tests, doctors’ visits or other benefits considered medically necessary by your doctor – these will be reviewed by our clinical team to ensure appropriateness.
Compliance
You need to:
- obtain your chronic medication on a monthly basis,
- make sure that you take your medication according to the dosage and quantity prescribed by your doctor, and
- make sure that you do not miss a dose - this is not only important for compliance, but it can have serious implications for your health and wellbeing.
Please make sure your claims have the appropriate ICD-10 code
It is important for all claims to include the appropriate ICD-10 codes (diagnostic codes), so we can identify the claim correctly and pay it from the Chronic Benefit.
We may pay claims from your Day-to-day Benefit 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 clinically appropriate.
Contact us
You can contact us via the web chat facility on momentummedicalscheme.co.za, email us at [email protected], send us a WhatsApp message or call us on 0860 11 78 59.
Glossary of terms
Designated service providers: Momentum Medical Scheme uses a network of designated service providers, such as Associated GPs and Specialists, as well as State facilities, depending on the circumstances, to diagnose and treat our members for the Prescribed Minimum Benefits.
A formulary is a list of medicines covered on your option, from which a doctor can prescribe the appropriate medication for your chronic condition.
ICD-10 is the diagnosis code.
Prescribed Minimum Benefits is a list of benefits for which all medical schemes in South Africa have to provide cover in terms of the Medical Schemes Act No 131 of 1998. The Prescribed Minimum Benefits include life-threatening emergency medical conditions, a defined set of 271 diagnoses and 26 chronic conditions. Benefits are covered in full if you use the Scheme’s Designated Service Providers (DSPs). If you voluntarily choose to use non-designated service providers, the Scheme will pay benefits up to the Momentum Medical Scheme Rate and relevant co-payments will apply. If you use non-designated service providers in a life-threatening emergency, it is deemed involuntary and co-payments are therefore waived.