Emergency / crisis support: /emergency
If you are facing a large device implantation bill, a declined Entresto application, or repeated hospitalisation costs that are exceeding your scheme's tolerance — this guide covers your options.
In Hospital Now (Acute Decompensated Heart Failure)
If you are currently admitted for acute heart failure: 1. Confirm PMB coverage is active — acute decompensated heart failure is PMB; the scheme cannot refuse emergency inpatient care. 2. Request a case manager through your scheme's hospitalisation line. 3. If the admission was unplanned, retrospective pre-authorisation can be obtained — the hospital's billing department or social worker can assist. 4. Before discharge, ensure your cardiologist has submitted or intends to submit for any device therapy that may be recommended at follow-up.
Common Cardiomyopathy Financial Crises
1. Entresto declined; cardiologist insists it is first-line The scheme's CDL formulary does not include Entresto; exceptional-needs was refused.
2. ICD or CRT-D device shortfall The device and procedure were covered at tariff; the implanting specialist billed well above tariff.
3. CDL medications being charged to MSA Registration was not completed or was rejected; medications are depleting the savings account.
4. SGLT2 inhibitor declined for HF indication Scheme refuses empagliflozin or dapagliflozin citing "diabetes-only" indication.
5. Repeated hospitalisations exhausting in-hospital benefit Advanced HF with frequent acute admissions is consuming the annual hospitalisation benefit limit.
If Entresto Was Declined
Step 1: Request written decline with clinical rationale. Step 2: Ask your cardiologist to submit an enhanced exceptional-needs motivation citing: your EF, NYHA class, current medication intolerance or suboptimal response on ACE inhibitor, PARADIGM-HF trial mortality data, and ESC 2021 guideline Class I recommendation. Step 3: Request a peer-to-peer review between your cardiologist and the scheme's medical advisor. Step 4: If declined again, submit a formal internal appeal. Step 5: Escalate to the CMS if the internal appeal fails. The CMS has adjudicated on Entresto in favour of patients where the ESC guideline recommendation is clearly documented.
In the interim, continue your ACE inhibitor at optimal dose while the appeal is active.
If Your SGLT2 Inhibitor Was Declined
The HF indication for empagliflozin and dapagliflozin in non-diabetic patients is a Class I recommendation in current ESC guidelines. If your scheme declines: - Submit exceptional-needs motivation with your EF, NYHA class, and reference to EMPEROR-Reduced / DAPA-HF trial results. - Specify the non-diabetic HF indication explicitly — some scheme formulary systems automatically classify SGLT2 inhibitors under "diabetes" and reject HF-indication claims unless the motivation clearly states HF as the primary indication.
If Your Device Implantation Bill Is Large
ICD and CRT-D implantation generate significant specialist shortfalls in SA private practice:
- Obtain itemised accounts from the electrophysiologist/cardiologist and the hospital separately.
- Cross-reference against scheme remittance advice to identify the shortfall per item.
- Submit to your gap cover provider — shortfalls on device implantation are a typical gap cover claim.
- If the gap OPL (~R220,000/year) is insufficient to cover the full shortfall, contact the specialist practice for a payment arrangement on the balance.
If Recurrent Admissions Are Exhausting Your Benefit
In advanced cardiomyopathy with frequent decompensations, the PMB framework provides important protection: - Acute decompensated heart failure admissions are PMB. The scheme cannot refuse PMB emergency admissions regardless of annual limits. - Non-emergency maintenance admissions (e.g., elective IV diuresis) may be subject to in-hospital benefit limits — these are a grey area worth confirming with your scheme in advance.
If you are frequently hospitalised, request that your cardiologist proactively register you with the scheme's heart failure disease management programme, if one exists. These programmes often provide enhanced benefits and care coordination.
Advanced Heart Failure: When Standard Benefits Are Not Enough
In end-stage cardiomyopathy, patients may require consideration of left ventricular assist devices (LVADs) or cardiac transplantation. These fall outside standard CDL and PMB benefits: - LVAD implantation (bridge-to-transplant or destination therapy) is not a standard PMB benefit; it requires a separate scheme authorisation and is only performed at designated centres. - Cardiac transplantation is similarly outside standard PMB; transplant candidates are managed through a specialist authorisation pathway.
If your cardiologist raises either option, request a case conference with your scheme's medical advisory team before any clinical workup begins. The financial and authorisation pathway needs to be established in advance.
Triage Table
| Situation | Priority | Action |
|---|---|---|
| Acute HF without pre-auth | Urgent | Retrospective auth + PMB confirmation |
| CDL medications on MSA | High | CDL registration + reprocessing request |
| Entresto exceptional-needs declined | High | Enhanced motivation + peer-to-peer + CMS |
| SGLT2 inhibitor declined (HF indication) | High | Exceptional-needs with HF-specific motivation |
| Device implantation shortfall | Medium | Gap cover claim + payment plan on balance |
| Repeated admissions hitting limits | Medium | Confirm PMB status of admissions; disease management programme |
Escalation Contacts
Council for Medical Schemes (CMS): 0861 123 267 | www.medicalschemes.org.za Heart and Stroke Foundation SA: 021 422 1586 AURA Emergency: /emergency
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This page is general information about medical schemes. It is not medical advice: speak to a healthcare professional about your own treatment. Medical aid and gap cover advice is given by Eldon de Waal, a Supervised Representative of Approach Administration (FSP 23579).