Non-Established, New or Emerging Treatments and Services (NeNETS) policy
The TAC medical excess may apply to these services (excludes rehabilitation equipment).
The TAC can consider paying the reasonable costs of non-established, new or emerging treatments and services (equipment, medications, prostheses, procedures, or surgeries) only in exceptional circumstances when required as a result of a transport accident injury. For a request to be considered by the TAC, the requesting practitioner must provide strong clinical evidence of the safety and efficacy of the non-established, new or emerging treatments and services.
Non-established, new or emerging treatments and services can be paid under sections 23 and 60 of the Transport Accident Act 1986 (the Act).
TAC decisions regarding treatments and services are guided by the Medical Services Advisory Committee (MSAC), the Medicare Benefits Schedule (MBS), the Prostheses List Advisory Committee (PLAC), the Department of Health and Ageing Prostheses List, Pharmaceutical Benefits Advisory Committee (PBAC), the Pharmaceutical Benefits Schedule (PBS), the Australian Register of Therapeutic Goods (ARTG), and evidence-based medicine.
The TAC defers to decisions made by these bodies where such decisions exist. Where such decisions do not exist, consideration will only be given to non-established, new or emerging treatments and services requests, where the medical practitioner provides strong clinical evidence (National Health & Medical Research Council [NHMRC] Level 1 or 2) of the safety and efficacy of the treatment and/or service.
This policy should be read in conjunction with the following, as relevant:
- NHMRC levels of evidence and grades for recommendations for developers of guidelines
- Doctor appointments/medical services policy
- Surgery policy
- Medications policy
- other related TAC policies.
In this policy, non-established, new or emerging treatments and services includes (but are not limited to):
- Equipment and other interventions which are not regulated by the PBAC, MSAC or PLAC and are not the subject of a previous negative decision by the PBAC, MSAC or PLAC.
- Medication not on the PBS and/or not registered with the ARTG and not the subject of a previous negative decision by the PBAC or the ARTG (this includes vitamins, minerals, and off-label prescribing, i.e. where the intended use differs from that in the product information in the form of dose, age, indication or route).
- Prostheses not on the Prosthesis List and not the subject of a previous negative decision by the PLAC.
- Procedures and operations not on the MBS and not the subject of a previous negative decision by the MSAC.
- Other treatments (equipment, medications, prostheses, procedures, or surgeries) not covered by existing TAC policies.
What can the TAC pay for in relation to non-established, new or emerging treatments and services?
The TAC can pay the reasonable costs of non-established, new or emerging treatments and services that are:
- required as a result of a transport accident injury
- required following a reasonable trial of all available established treatments and services
- considered for an exceptional circumstance
- supported by strong clinical evidence (NHMRC Level 1 or 2)
- in accordance with relevant TAC policies.
Who can provide non-established, new or emerging treatments and services?
Non-established, new or emerging treatments and services can be performed or supplied by:
- a qualified and registered medical practitioner, dentist, optometrist, physiotherapist, chiropractor, osteopath, podiatrist or occupational therapist, or
- a provider authorised by the TAC to provide that service.
What information does the TAC require to consider paying for non-established, new or emerging treatments and services?
For the TAC to consider paying the reasonable costs of non-established, new or emerging treatments and services, a request must be made in writing to the TAC and include the following information:
- diagnosis and relationship to the transport accident injury
- evidence (NHMRC Level 1 or 2) that the proposed treatment or service will be safe and effective. In exceptional circumstances, consideration may be given to a request for a non-established, new or emerging treatment or service where evidence can be supplied that the proposed treatment is consistent with the Clinical Framework. Where multiple pieces of high level evidence exist, all the evidence will be reviewed to determine if the treatment is in the client's best interests
- details of all previously trialed treatments and services for this diagnosis and their measurable outcomes
- if established treatments and services have not been trialed, reasons for going directly to a non-established, new or emerging treatment or service must be given
- clinical indications for requested treatment or service
- description and expected costs of proposed treatment or service
- objective outcome measures to be used and timing of assessment
- expected outcomes from proposed treatment or service, including functional outcomes (such as return to work, increased independence in domestic duties, etc.) how and when effectiveness will be assessed
- future treatments and services planned if proposed treatment or service is successful or unsuccessful
- the urgency of the request
- the name and qualifications of the requesting provider
- the name, qualifications, skills and experience of the provider(s) performing the treatment or service.
A request for non-established, new or emerging treatments and services will not be considered without the above information.
When will the TAC respond to a request?
To assist the TAC to make a decision regarding a request for non-established, new or emerging treatments and services, the request will be reviewed by the TAC Clinical Panel. The Clinical Panel may contact the requesting medical practitioner to seek further information and/or discuss the proposed treatment or service prior to making a recommendation to the TAC regarding the request. The TAC will respond to the request when they have received the Clinical Panel's recommendation.
What fees are payable for non-established, new or emerging treatments and services?
The TAC will assess the expected cost information provided by the requesting provider for reasonable cost on a case by case basis.
The TAC will communicate the reasonable cost to the requesting provider in writing in the treatment or service approval letter.
In relation to non-established, new or emerging treatments and services, what won't the TAC pay for?
The TAC will not pay for:
- off-label use of medication where there is insufficient evidence to support its use
- prostheses or minerals or any therapeutic good that has been listed, as opposed to registered, on the ARTG except for those described in the Medications policy
- Lokomat Body Weight Supported Treadmill Training (BWSTT) therapy (see the Evidence Review on the ISCCR website)
- telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals
- fees associated with cancellation or non-attendance
- treatments and services:
- which are part of any research project or experiment
- subcontracted to, or provided by, a provider who is not a registered and approved TAC provider
- provided by telephone or other non face to face mediums
- provided more than once on the same day to the same client
- for a person other than the client
- for a condition that existed before the transport accident injury or that is not a result of the transport accident injury
- provided outside the Commonwealth of Australia
- provided more than two years prior to the request for funding except where the request for payment is made within three years of the transport accident. Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy
- provided by a member of the client's immediate family.