Discovery Health Request for Additional Cover PMB Form

Discovery Health Request for Additional Cover PMB Form Date: 01 November 2024 Practice Number: 1234567 Medical Aid Number: 123456789 Main Member ID: 8501015000084 Authorisation Number: N/A Patient Details: Surname: Smith First Name: John Date of Birth: 01/01/1985 Contact Number: 0721234567 Diagnosis: ICD10 Code 1: J45.9 (Asthma, unspecified) ICD10 Code 2: E11.9 (Type 2 diabetes mellitus without complications) Motivation: Mr. John Smith, a 39-year-old male, presents with a history of poorly controlled asthma and newly diagnosed type 2 diabetes. Despite adherence to current bronchodilator therapy (salbutamol and budesonide inhaler) and metformin, his asthma symptoms have been escalating with increased frequency of nocturnal awakenings and exertional dyspnoea, leading to a significant impact on his quality of life and ability to perform daily activities. His recent spirometry demonstrates FEV1 65% predicted, indicative of moderate persistent asthma. Furthermore, his HbA1c is 8.2%, despite optimal lifestyle modifications and metformin, suggesting inadequate glycaemic control. Additional Cover Requested: Additional cover is requested for a specialist pulmonology consultation and subsequent initiation of biological therapy (e.g., omalizumab) for his severe persistent asthma, as per GINA guidelines. For his diabetes, an endocrinology consultation is sought to evaluate potential intensification of hypoglycaemic agents, including GLP-1 receptor agonists, to achieve optimal glycaemic targets and prevent long-term complications. These interventions are deemed medically necessary to improve symptom control, prevent exacerbations, and reduce the risk of diabetes-related comorbidities, aligning with his Prescribed Minimum Benefits (PMB) for chronic conditions that are not adequately managed by standard care. Without this additional cover, Mr. Smith's chronic conditions are likely to deteriorate, leading to increased healthcare utilisation and poorer health outcomes. Supporting Clinical Information: Relevant clinical history: * Asthma diagnosed in childhood, well-controlled until 6 months ago. * Recent increase in reliever inhaler use (more than 3 times a week). * Two asthma exacerbations requiring oral corticosteroids in the last 3 months. * Family history of asthma and type 2 diabetes. * Non-smoker. Relevant examination findings: * Respiratory: Mild bilateral expiratory wheeze, otherwise clear to auscultation. * Cardiovascular: Regular rhythm, no murmurs. * Abdomen: Soft, non-tender, no organomegaly. * BMI: 28 kg/m². Relevant investigations: * Spirometry: FEV1 65% predicted, FEV1/FVC 0.68. * HbA1c: 8.2%. * Fasting blood glucose: 9.8 mmol/L. * Chest X-ray: No acute infiltrates or consolidation. Proposed Treatment Plan: * Referral to Pulmonologist for assessment of severe asthma and consideration of biological therapy. * Referral to Endocrinologist for assessment of poorly controlled type 2 diabetes and consideration of additional glucose-lowering medications. * Continued lifestyle advice and adherence to current medications. * Regular monitoring of asthma control and blood glucose levels. Referring Doctor Details: Dr. Thomas Kelly Signature: [Doctor's Signature] Date: 01 November 2024