A cardiomyopathy diagnosis — whether following a hospital admission for breathlessness, an incidental echocardiogram finding, or a family screening after a relative's sudden cardiac death — raises immediate questions about what your medical aid will cover, and for how long. Here are the key answers.
Does My Medical Aid Have to Cover This?
Yes. Cardiomyopathy is a Chronic Disease List (CDL) condition. Your scheme must fund CDL-registered medications indefinitely. Acute decompensations requiring hospitalisation are covered under PMB. This is a lifetime benefit — cardiomyopathy is chronic and the CDL obligation does not expire.
Register for the CDL Benefit Immediately
Call your scheme's chronic benefits department and register your diagnosis. You will need: - A cardiologist or specialist physician letter confirming cardiomyopathy (ICD-10: I42) - Echocardiogram report showing reduced ejection fraction or structural abnormality - The scheme's CDL registration form
Until you are registered, your medications may be charged to your medical savings account. Once registered, they shift to the CDL benefit — ring-fenced, protected, and not subject to savings depletion.
Entresto: Will My Scheme Cover It?
Sacubitril/valsartan (Entresto) is now recommended as first-line therapy for HFrEF by the European Society of Cardiology and South African heart failure guidelines. It has demonstrated a 20% relative reduction in cardiovascular mortality versus ACE inhibitors in the landmark PARADIGM-HF trial.
Whether your scheme covers it under CDL depends on your specific plan. Three scenarios: 1. CDL formulary includes Entresto: It is funded automatically once CDL-registered. 2. CDL formulary excludes it; exceptional-needs required: Your cardiologist submits a motivation. Most cardiologists are familiar with this process. Approval rates are high with a well-documented motivation. 3. Scheme declines: You can appeal citing current ESC guidelines. An internal appeal is the first step; CMS escalation if the appeal fails.
Monthly cost if self-funded: ~R3,500. It is worth pursuing scheme funding.
SGLT2 Inhibitors for Heart Failure: Getting Them Funded
If your cardiologist has prescribed empagliflozin (Jardiance) or dapagliflozin (Forxiga) for HFrEF in the absence of diabetes, expect this to require an exceptional-needs motivation. The HF indication for SGLT2 inhibitors in non-diabetic patients is relatively new (post-2020 trial publications) and many scheme CDL formularies have not yet universally incorporated it.
Your cardiologist's motivation should reference: current EF, functional class (NYHA), the EMPEROR-Reduced (empagliflozin) or DAPA-HF (dapagliflozin) trial results, and the ESC 2021 HF guideline recommendation (Class I, Level A). This medication combination has a strong clinical evidence base — a well-structured motivation should achieve approval.
Device Therapy: ICD or CRT-D — What to Expect
If your cardiologist has recommended an ICD or CRT-D device: - Pre-authorisation is mandatory before implantation. Do not book the procedure without written pre-authorisation. - Confirm separately whether the device cost and the procedure cost are both pre-authorised — they are typically billed separately. - Ask the implanting electrophysiologist or interventional cardiologist whether they bill at medical aid tariff or above it. Shortfalls on device implantation can be R30,000–R80,000. - Check whether your scheme has a specific device sub-limit or covers device costs under the general in-hospital benefit.
Acute Admissions: When You Need to Go to Hospital
If you are breathless at rest, severely oedematous, or experiencing orthopnoea (breathlessness lying flat), go to hospital. Acute decompensated heart failure is a PMB emergency. Your scheme cannot refuse to cover emergency hospitalisation.
Contact your cardiologist or GP simultaneously so they can liaise with the hospital and ensure the pre-authorisation and case management processes are activated correctly from the outset.
The Next Three Months: Practical Checklist
| Action | Priority |
|---|---|
| Register for CDL benefit (ICD-10: I42) | Immediate |
| Confirm medications are being processed under CDL | Within 2 weeks |
| Pre-authorise all planned device procedures | Before any booking |
| Ask cardiologist whether Entresto application is needed | At next appointment |
| Check SGLT2 inhibitor coverage for HF indication | If empagliflozin/dapagliflozin prescribed |
| Confirm gap cover status and OPL | This week |
| Ask about heart failure disease management programme | With scheme |
Understanding Your Ejection Fraction Number
Your echocardiogram report will include an ejection fraction (EF) percentage. This number guides treatment decisions and, importantly, determines eligibility for device therapy:
- EF 40–55% (mildly reduced): Heart failure with mildly reduced EF (HFmrEF); oral medications; device therapy usually not indicated.
- EF <40% (reduced): HFrEF — the four-pillar drug protocol plus Entresto is standard of care.
- EF <35% (significantly reduced): ICD consideration for sudden cardiac death prevention; CRT-D if LBBB is present.
Keep a copy of your most recent echocardiogram report. Your scheme may request EF documentation for Entresto exceptional-needs applications and device pre-authorisations.
Managing Fluid Retention: Why Diuretics Matter
Furosemide (a loop diuretic) is the mainstay of fluid management in heart failure. It is typically CDL-funded once you are registered. Dose adjustments may be needed during periods of fluid overload — your cardiologist or heart failure nurse may advise you on a flexible dosing protocol ("sliding scale") based on daily weight monitoring. Daily weights (first thing in the morning) are a key self-monitoring tool; a weight gain of more than 2kg over 2 days typically warrants a call to your cardiologist.
Can Heart Failure Improve?
In some cases of dilated cardiomyopathy — particularly if caused by a reversible trigger (viral myocarditis, peripartum cardiomyopathy, tachycardia-induced) — the heart muscle can partially or fully recover with optimal medical therapy. This recovery process takes months to years. Your cardiologist will schedule repeat echocardiograms to track EF changes. Even if your EF does not fully normalise, the four-pillar protocol consistently reduces symptoms and prolongs life.
Support Resources
Heart and Stroke Foundation South Africa: www.heartfoundation.co.za | 021 422 1586 Cardiac support, patient education
South African Heart Association (SAHA): www.saheart.org Clinical resources, patient pathways
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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).