Surgically Implanted Prostheses

The TAC Medical Excess may apply to these services 

 

 

POLICY

The TAC can pay the reasonable costs of a surgically implanted prosthesis when required as a result of a transport accident injury under 60 of the Transport Accident Act 1986 (the Act).

The TAC adopts the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for surgical services provided by medical practitioners.

This policy must be read in conjunction with the following:

For information regarding External Prostheses, including artificial limbs, please refer to the External Prostheses and Orthoses policy.

BACKGROUND

A Surgically implanted prostheses are provided in a hospital setting.  For information regarding hospital services associated with surgically implanted prostheses, please see the applicable Hospitals policy.  For surgically implanted prostheses to manage pain, please also see the Implantable Pain Therapy policy

The TAC refers to the Prostheses List, published by the Department of Health and Aging (DoHA), to determine which prostheses are clinically effective and the reasonable cost of these prostheses. The Prostheses List has more than 9000 surgically implanted prostheses, including products such as hip and knee replacements, human tissues and other medical devices. The DoHA and an advisory committee of medical practitioners and other health specialists known as the Prostheses List Advisory Committee (PLAC), evaluate prostheses for inclusion on the Prostheses List by determining which ones are safe and clinically effective. The evidence shows that the most expensive prostheses are not necessarily the most appropriate ones. The list comprises no-gap and gap-permitted prostheses.

For a prosthesis to be included on the Prostheses List there must be an associated item on the Medicare Benefit Schedule (MBS) that applies to the surgical procedure required to implant that prosthesis.

DEFINITIONS

In this policy:

  • A surgically implanted prosthesis is an item of equipment or a device that is surgically implanted by a medical practitioner to improve health outcomes for clients. Prostheses include, but are not limited to, screws, plates, nails and human tissue.
  • No-gap prostheses are items listed on the Prostheses List with a single fee and have been assessed as having equivalent clinical effectiveness to gap-permitted prostheses.  
  • Gap-permitted prostheses have both a minimum and maximum fee listed on the Prostheses List. Gap-permitted items have no proven improved clinical outcomes in comparison with no-gap prostheses.
  • Non-listed prostheses are prostheses that do not appear on the Prostheses List. These prostheses have either been rejected by the PLAC or have not yet been evaluated for inclusion on the Prostheses List. 

GUIDELINES

What can the TAC pay for in realtion to surgically implanted prostheses?

The TAC can pay for surgically implanted prostheses that are:

  • currently included on the Prostheses List
  • required as a result of the transport accident injury
  • reasonable, necessary and appropriate in the circumstances
  • clinically justified, safe and effective
  • invoiced in accordance with the Prostheses List and TAC's guidelines.

The TAC will not pay for surgically implanted prostheses which have been the subject of a negative determination by the PLAC.

When replacement or modification of a prosthesis is required, and the prosthesis is covered by a supplier/manufacturer warranty, it is the responsibility of the manufacturer to replace or modify the prosthesis or its components.

Who can provide surgically implanted prostheses?

Suitably qualified registered medical practitioners can surgically implant prostheses in a hospital setting.

What information does the TAC require to consider paying for surgically implanted prostheses?

Requests for surgically implanted prostheses will be assessed on an individual basis and will be considered as part of the review process for elective surgery (refer to the Surgery (Elective) policy).

To facilitate a timely decision and payment of invoices, the TAC encourages prior approval to be sought by the treating surgeon. The approval of prostheses used within a surgical procedure will be considered as part of the elective surgery review process (see the Surgery (Elective) policy).

The TAC requires specific information when considering paying for surgically implanted prostheses, as follows:

No–gap prosthesesIf a medical practitioner is requesting approval for a surgical procedure that will involve the use of a surgically implanted prosthesis, details of the anticipated no-gap prostheses are required.

Gap-permitted prosthesesIf a medical practitioner believes that a surgically implanted gap-permitted prosthesis is necessary, the TAC requires the following information in addition to the information required for approval of an elective surgery request:

  • Clinical justification for the use of a gap-permitted prosthesis instead of a standard no-gap prosthesis
  • The prosthesis supply code and description
  • The cost of the prosthesis.

Non-listed prosthesesThe TAC is unable to pay for surgically implanted prostheses which have been the subject of a negative determination by the PLAC. 

Requests for surgically implanted prostheses not yet evaluated by the PLAC will only be considered in exceptional circumstances.

For surgically implanted prostheses that have not yet been evaluated by the PLAC, please refer to the Non-Established, New or Emerging Treatments and Services.

Emergency situationsIn emergency situations, no-gap or gap-permitted prostheses may be used at the medical practitioner's discretion. However, where gap-permitted prostheses are used, clinical justification may be required by the TAC as soon as possible after hospital admission to consider paying for the reasonable costs of the gap item.

When will the TAC respond to a request?

The TAC will respond to written treatment and service requests as set out in the TAC Service Charter.

What are the TAC's invoice requirements?

For standard invoice requirements, refer to the TAC Invoice Standards

In addition to these requirements, please ensure that invoices for surgically implanted prostheses also include the following admission and treatment details:

  • Admission and discharge dates
  • ICD-AM-10 v5 diagnosis codes and description
  • Theatre band (NPBC and APHA)
  • Prostheses codes - description and cost including whether the item is listed on the Prostheses List or is a gap-permitted item
  • List of consumables and disposables
  • Accommodation classification
  • Itemised list of discharge medications.

What fees are payable for surgically implanted prostheses?

The TAC will pay the listed price for a no-gap prosthesis on the Prostheses List or the minimum listed price for a gap-permitted prosthesis on the Prosthesis List.

The TAC can pay for prostheses surgically implanted by qualified medical practitioners, where the surgery is performed in accordance with the applicable MBS items, explanations, definitions, rules and conditions unless otherwise specified by the TAC.

In relation to Surgically Implanted Prostheses, what won't the TAC pay for?

The TAC will not pay for:

  • treatment or services for a person other than the injured client
  • prostheses required for a condition that existed before the transport accident or that is not a result of the transport accident
  • surgically implanted prostheses that have been the subject of a negative determination by the PLAC
  • prostheses where there is no adequate clinical justification for use
  • prostheses where the cost is included in the hospital bed fee, i.e. for public hospitals
  • prostheses handling fees
  • modification or replacement of a surgically implanted prostheses that is covered by supplier/manufacturer warranty
  • any prosthetic component which is not implanted in the client (for example, a prosthetic component which is opened but not used, or the components of a external fixator kit that are not used)
  • prostheses which are used for sizing purposes and form part of a reusable kit
  • treatment or services provided outside the Commonwealth of Australia
  • treatment or services provided by telephone or other non face-to-face mediums
  • the cost of telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals
  • treatment, services or equipment where there is no published evidence in a recent peer-reviewed journal article that the treatment, service or equipment is safe and effective. Refer to the Non-Established, New or Emerging Treatments and Services policy 
  • treatment, services or prostheses provided more than 2 years prior to the request for funding except where the request for payment is made within 3 years of the transport accident. Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy.

Medical Services Reimbursement Rates

The TAC has adopted the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for services provided by medical practitioners.  When invoicing for medical services, medical practitioners are expected to adhere to the MBS rules unless otherwise specified by the TAC in the Reimbursement Rates for Medical Services booklet or its medical policies.

The Reimbursement Rates for Medical Services booklet below must be read in conjunction with:

Current Rates

Previous Rates

At the time of production this publication contained up to date information as released by Medicare Australia (Medicare).  The relevant publication will be updated to reflect any further changes that are implemented by Medicare each year.  Please check our website for the latest version.

If you have any questions about these publications or the reimbursement rates, please contact the TAC on 1300 654 329. Alternatively, e-mail info@tac.vic.gov.au.