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Determinations/Health as amended, taking into account amendments up to Health Insurance (Section 3C Diagnostic Imaging – Nuclear Medicine Services) Amendment Determination 2020
Administered by: Health
Registered 16 Dec 2020
Start Date 01 Dec 2020

Commonwealth Coat of Arms of Australia

Health Insurance (Section 3C Diagnostic Imaging – Nuclear Medicine Services) Determination 2019

made under subsection 3C(1) of the

Health Insurance Act 1973

Compilation No. 3

Compilation date:                           1 December 2020

Includes amendments up to:         F2020L01513

Registered:                                      16 December 2020

About this compilation

This compilation

This is a compilation of the Health Insurance (Section 3C Diagnostic Imaging – Nuclear Medicine Services) Determination 2019 that shows the text of the law as amended and in force on 1 December 2020 (the compilation date).

The notes at the end of this compilation (the endnotes) include information about amending laws and the amendment history of provisions of the compiled law.

Uncommenced amendments

The effect of uncommenced amendments is not shown in the text of the compiled law. Any uncommenced amendments affecting the law are accessible on the Legislation Register (www.legislation.gov.au). The details of amendments made up to, but not commenced at, the compilation date are underlined in the endnotes. For more information on any uncommenced amendments, see the series page on the Legislation Register for the compiled law.

Application, saving and transitional provisions for provisions and amendments

If the operation of a provision or amendment of the compiled law is affected by an application, saving or transitional provision that is not included in this compilation, details are included in the endnotes.

Editorial changes

For more information about any editorial changes made in this compilation, see the endnotes.

Modifications

If the compiled law is modified by another law, the compiled law operates as modified but the modification does not amend the text of the law. Accordingly, this compilation does not show the text of the compiled law as modified. For more information on any modifications, see the series page on the Legislation Register for the compiled law.

Self‑repealing provisions

If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.

  

  

 


Contents

1.               Name  1

3.               Authority  1

4.               Definitions  1

5.               Treatment of relevant services  2

6.               Application of Items in Schedule 1  2

7.           Application Periods in Schedule 2                                                           2

Schedule 1 – relevant services  3

Schedule 2 – closed periods of application  10

Endnotes

Endnote 1—About the endnotes                                   11

Endnote 2—Abbreviation key                                                                                    12

Endnote 3—Legislation history                                                                                 13

Endnote 4—Amendment history                                                                                14

 


1.         Name

This instrument is the Health Insurance (Section 3C Diagnostic Imaging – Nuclear Medicine Services) Determination 2019.

3.         Authority

This instrument is made under subsection 3C(1) of the Health Insurance Act 1973.

4.         Definitions

(1)               In this instrument:

Act means the Health Insurance Act 1973.

general medical services table means the table prescribed under subsection 4(1) of the Act.

Modified Monash 3 area has the meaning given by clause 7.1.1 of the general medical services table.

Modified Monash 4 area has the meaning given by clause 7.1.1 of the general medical services table.

Modified Monash 5 area has the meaning given by clause 7.1.1 of the general medical services table.

Modified Monash 6 area has the meaning given by clause 7.1.1 of the general medical services table.

Modified Monash 7 area has the meaning given by clause 7.1.1 of the general medical services table.

PET means positron emission tomography.

relevant provisions means all provisions, of the Act and regulations made under the Act, and the National Health Act 1953 and regulations made under the National Health Act 1953, relating to medical services, professional services or items.

relevant service means a health service, as defined in subsection 3C(8) of the Act, that is specified in the Schedule.

Schedule means the Schedule to this instrument.

Note:       The following terms are defined in subsection 3(1) of the Act:

·     clinically relevant service

·     diagnostic imaging services table

·     item

·     professional service

(2)        Unless the contrary intention appears, a reference in this instrument to a provision of the Act or the National Health Act 1953 or regulations made under the Act or under the National Health Act 1953 as applied, adopted or incorporated in relation to specifying a matter is a reference to those provisions as in force from time to time and any other reference to provisions of an Act or regulations is a reference to those provisions as in force from time to time.

5.         Treatment of relevant services

                   For subsection 3C(1) of the Act a relevant service, provided in accordance with this instrument and as a clinically relevant service, is to be treated, for the relevant provisions of the Act, the regulations, the National Health Act 1953 or the regulations under that Act, as if:

(a)          it were both a professional service and a medical service; and

(b)          there were an item in the diagnostic imaging services table that:

(i)           related to the service; and

(ii)          specified for the service a fee in relation to each State, being the fee specified in the Schedule in relation to the service.

6.           Application of Items in Schedule 1

(1)        Paragraphs 2.4.1(b) and (c) of the diagnostic imaging services table shall have effect as if items in Schedule 1 of this instrument were specified for the purpose of those paragraphs.

7.           Application periods in Schedule 2

During the period or periods specified in Schedule 2 of this instrument, items in Schedule 1 of this instrument apply but not otherwise.


Schedule 1 – relevant services

1.1.1  Restriction on items for stress myocardial perfusion studies—patients, requests and requirements

                   Items 61311, 61332, 61365, 61377, 61380 and 61418 apply to a service performed on a patient only if:

(a)   one or more of subclauses 1.1.2(1), (2) and (3) apply to the patient; and

(b)   the request for the service identifies any symptoms or clinical indications mentioned in those subclauses that apply to the patient; and

(c)   the service is performed in accordance with clause 1.1.3.

1.1.2  Stress myocardial perfusion studies – patient

             (1)  This subclause applies to a patient if:

(a)   the patient displays symptoms of typical or atypical angina, including constricting discomfort of one or more of the following:

                                   (i)         the front of the chest;

                                   (ii)        the neck;

                                   (iii)       the shoulders;

                                   (iv)       the jaw;

                                   (v)        the arms; or

(b)   the patient’s symptoms are:

                                   (i)         precipitated by physical exertion; or

                                   (ii)        relieved within 5 minutes or less by rest or glyceryl trinitrate.

             (2)  This subclause applies to a patient if:

(a)   the patient has known coronary artery disease; and

(b)   the patient displays one or more symptoms that are suggestive of ischaemia; and

(c)   the symptoms:

                                   (i)         are not adequately controlled with medical therapy; or

                                   (ii)        have evolved since the last functional study undertaken of the patient.

             (3)  This subclause applies to a patient if one or more of the following clinical indications apply to the patient:

(a)   the patient does not have a known coronary artery disease but assessment indicates that resting twelve‑lead electrocardiogram changes are consistent with coronary artery disease or ischaemia;

(b)   coronary artery disease related lesions, of uncertain functional significance, have previously been identified on a computed tomography coronary angiography or invasive coronary angiography;

(c)   an assessment by a specialist or consultant physician indicates that the patient has possible painless myocardial ischaemia, where a stress myocardial perfusion study is likely to assist the diagnosis;

(d)   an assessment indicates that the patient has undue exertional dyspnoea of uncertain aetiology;

(e)   a pre‑operative assessment of the patient, who has a functional capacity of less than 4 metabolic equivalents, confirms that surgery is an intermediate to high risk, and the patient also has at least one of the following conditions:

                                   (i)         ischaemic heart disease;

                                   (ii)        previous myocardial infarction;

                                   (iii)       heart failure;

                                   (iv)       stroke;

                                   (v)        transient ischaemic attack;

                                   (vi)       renal dysfunction (serum creatinine greater than 170umol/L or 2 mg/dL or a creatinine clearance of less than 60 mL/min);

                                   (vii)      diabetes mellitus requiring insulin therapy;

(f)   assessment, including quantification, is required before either percutaneous coronary intervention or coronary bypass surgery to quantify the extent and severity of myocardial ischaemia, and to ensure the criteria for intervention are met;

(g)   assessment is required of relative amounts of ischaemic viable myocardium and non‑viable (infarcted) myocardium because the patient has a previous myocardial infarction;

(h)   assessment of myocardial ischaemia with exercise is required because the patient has congenital heart lesions, has undergone surgery and ischemia is considered possible;

(i)    the patient is under 17 years old, with coronary anomalies, and assessment of myocardial perfusion is required before and after cardiac surgery:

                                   (i)         for congenital heart disease; or

                                   (ii)        where there is a probable or confirmed coronary artery abnormality;

       (j)      myocardial perfusion abnormality is suspected but, due to the patient’s cognitive capacity or expressive language impairment, it is not possible to accurately assess symptom frequency based on medical history.

1.1.3 Stress myocardial perfusion studies—requirements

             (1)  A stress myocardial perfusion study must be performed:

(a)   on premises equipped with resuscitation equipment, including a defibrillator; and

(b)   by a person trained in cardiopulmonary resuscitation who is in continuous personal attendance during the procedure.

             (2)  At the time the service is performed, a second person trained in the matters mentioned in subclause (4) and cardiopulmonary resuscitation must be located at the premises while the exercise test is performed, and must be immediately available to respond if required.

             (3)  One of the persons mentioned in subclauses (1) and (2) must be a medical practitioner.

             (4)  For the purposes of subclause (2), the matters are:

(a)   how to safely perform exercise or pharmacological stress monitoring and recording; and

(b)   how to recognise the symptoms and signs of cardiac disease.

1.1.4  Restriction on items for myocardial perfusion studies

             (1)  Item 61311 does not apply to a service provided to a patient who is 17 years old or older if in the previous 24 months, a service associated with:

(a)   a service to which item 61332, 61377 or 61380 applies has been provided to the patient; or

(b)   a service to which item 61324, 61349, 61357, 61365, 61394, 61398, 61406, 61410, 61414 or 61418 of the diagnostic imaging services table applies has been provided to the patient

             (2)  Item 61332 does not apply to a service provided to a patient who is 17 years old or older if in the previous 24 months, a service associated with:

(a)   a service to which item 61311, 61377, 61380 or 61422 applies has been provided to the patient; or

(b)   a service to which item 61329, 61345, 61349, 61365, 61410 or 61418 of the diagnostic imaging services table applies has been provided to the patient.

             (3)  Item 61365 does not apply to a service provided to a patient if in the previous 12 months, a service associated with a service to which item 61349, 61410 or 61418 of the diagnostic imaging services table applies has been provided to the patient.

             (4)  Item 61377 does not apply to a service provided to a patient who is 17 years old or older if in the previous 24 months, a service associated with:

(a)   a service to which item 61311, 61332 or 61380 applies has been provided to the patient; or

(b)   a service to which item 61329, 61345, 61349, 61365, 61394, 61410, 61414 or 61418 of the diagnostic imaging services table applies has been provided to the patient.

             (5)  Item 61380 does not apply to a service provided to a patient who is 17 years old or older if in the previous 24 months, a service associated with:

(a)   a service to which item 61311, 61332, 61337 or 61422 applies has been provided to the patient; or

(b)   a service to which item 61349, 61365, 61398, 61406, 61410 or 61418 of the diagnostic imaging services table applies has been provided to the patient.

             (6)  Item 61418 does not apply to a service provided to a patient if in the previous 12 months, a service associated with a service to which item 61349, 61365 or 61410 of the diagnostic imaging services table applies has been provided to the patient.

             (7)  Item 61422 does not apply to a service provided to a patient who is 17 years old or older if in the previous 24 months, a service associated with:

(a)   a service to which item 61332 or 61380 applies has been provided to the patient; or

(b)   a service to which item 61321, 61325, 61329, 61345, 61349, 61365, 61410 or 61418 of the diagnostic imaging services table has been provided to the table.

             (8)  An item in Part 2 of the general medical services table does not apply to a service (the attendance service) provided to a patient on a day if either of the following is provided to the patient on the same day:

(a)   a myocardial perfusion study service to which item 61311, 61332, 61365, 61377, 61380, 61418 or 61422 of the diagnostic imaging services table applies.

             (9)  Subclause (6) does not apply if:

(a)   both:

                                   (i)         the attendance service is provided after another service is provided to the patient; and

                                   (ii)        clinical management decisions are made about the patient during that other service; or

(b)   the decision to perform the echocardiogram service or the myocardial perfusion study service on the same day is made as a result of a clinical assessment of the patient during the attendance service.

 

Group I4—Nuclear medicine imaging

Column 1

Item

Column 2

Description

Column 3

Fee ($)

61311

Single stress myocardial perfusion study, with PET if:

(a) the patient has symptoms of cardiac ischaemia; and

(b) at least one of the following applies:

(i) the patient has body habitus or other physical conditions (including heart rhythm disturbance) to the extent that a stress echocardiography would not provide adequate information;

(ii) the patient is unable to exercise to the extent required for a stress echocardiography to provide adequate information;

(iii) the patient has had a failed stress echocardiography provided in a service to which item 55141, 55143, 55145 or 55146 applies; and

(c) the service includes resting ECG, continuous ECG monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(d) the service is not associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61324, 61325, 61329, 61332, 61345, 61357, 61377, 61394, 61398, 61380, 61406, 61414 or 61422 applies.

Applicable not more than once in 24 months (R)

653.05

61332

 

Combined stress and rest, stress and re‑injection or rest and redistribution myocardial perfusion study, including delayed imaging or re‑injection protocol on a subsequent occasion, with PET, if:

(a) the patient has symptoms of cardiac ischaemia; and

(b) at least one of the following applies:

(i) the patient has body habitus or other physical conditions (including heart rhythm disturbance) to the extent that a stress echocardiography would not provide adequate information;

(ii) the patient is unable to exercise to the extent required for a stress echocardiography to provide adequate information;

(iii) the patient has had a failed stress echocardiography provided in a service to which item 55141, 55143, 55145 or 55146 applies; and

(c) the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(d) the service is not associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61311, 61321, 61324, 61325, 61329, 61345, 61357, 61377, 61380, 61394, 61398, 61406, 61414 or 61422 applies

Applicable not more than once in 24 months (R)

982.05

 

61365

Repeat combined stress and rest, stress and re‑injection or rest and redistribution myocardial perfusion study, including delayed imaging or re‑injection protocol on a subsequent occasion, with PET, if:

(a) in the previous 24 months, the patient has had a service performed to which item 61311, 61324, 61329, 61332, 61345, 61357, 61377, 61380, 61394, 61398, 61406 or 61414 applies and has subsequently undergone a revascularisation procedure; and

(b) the patient has one or more symptoms of cardiac the patient has symptoms of cardiac ischaemia that have evolved and are not adequately controlled with optimal medical therapy; and

(c) at least one of the following applies:

(i) the patient has body habitus or other physical conditions (including heart rhythm disturbance) to the extent that a stress echocardiography would not provide adequate information;

(ii) the patient is unable to exercise to the extent required for a stress echocardiography to provide adequate information;

(iii) the patient has had a failed stress echocardiography provided in a service to which item 55141, 55143, 55145 or 55146 applies; and

(d) the service is requested by a specialist or a consultant physician; and

(e) the service is not associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61349, 61410 or 61418 applies

Applicable not more than once in 12 months (R)

982.05

61377

 

Single stress myocardial perfusion study, with PET, if:

(a) the patient has symptoms of cardiac ischaemia; and

(b) the service is provided at, or from, a practice located in a Modified Monash 3, 4, 5, 6 or 7 area; and

(c) a stress echocardiography service is not available in the Modified Monash area where the service is provided; and

(d) the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(e) the service is not associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61311, 61321, 61324, 61325, 61329, 61332, 61345, 61357, 61380, 61394, 61398, 61406, 61414 or 61422 applies

Applicable not more than once in 24 months (R)

653.05

61380

Combined stress and rest, stress and re‑injection or rest and redistribution myocardial perfusion study, including delayed imaging or re‑injection protocol on a subsequent occasion, with PET, if:

(a) the patient has symptoms of cardiac ischaemia; and

(b) the service is provided at, or from, a practice located in a Modified Monash 3, 4, 5, 6 or 7 area; and

(c) a stress echocardiography service is not available in the Modified Monash area where the services is provided; and

(d) the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(e) the service is not associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61311, 61321, 61324, 61325, 61329, 61332, 61345, 61357, 61377, 61394, 61398, 61406, 61414 or 61422 applies

Applicable not more than once in 24 months (R)

982.05

61418

 

Repeat combined stress and rest, stress and re‑injection or rest and redistribution myocardial perfusion study, including delayed imaging or re‑injection protocol on a subsequent occasion, with PET, if:

(a) in the previous 24 months, the patient has had a service performed to which item 61311, 61324, 61329, 61332, 61345, 61357, 61377, 61380, 61394, 61398, 61406 or 61414 applies, and has subsequently undergone a revascularisation procedure; and

(b) the patient has one or more symptoms of cardiac ischaemia that have evolved and are not adequately controlled with optimal medical therapy; and

(c) the service is provided at, or from, a practice located in a Modified Monash 3, 4, 5, 6 or 7 area; and

(d) a stress echocardiography service is not available in the Modified Monash area where the service is provided; and

(e) the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(f) the service is not associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61349, 61365 or 61410 applies

Applicable not more than once in 12 months (R)

982.05

61422

Single rest myocardial perfusion study for the assessment of the extent and severity of viable and non‑viable myocardium, with PET, if:

(a) the patient has left ventricular systolic dysfunction and probable or confirmed coronary artery disease; and

(b) technetium is not available and the service uses an equivalent protocol to the single rest technetium‑99m (Tc‑99m) protocol; and

(c) the service is requested by a specialist or a consultant physician; and

(d) the service is not associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61311, 61321, 61324, 61325, 61329, 61332, 61345, 61357, 61377, 61380, 61394, 61398, 61406 or 61414 applies

Applicable not more than once in 24 months (R)

329.00

61333

Lung perfusion study and lung ventilation study using galligas or 68Ga‑MAA, with PET (R)

443.35

61336

Cerebral perfusion study, with PET (R)

605.05

61337

Bone study—whole body, with PET, when undertaken, blood flow, blood pool and delayed imaging on a separate occasion (R)

479.80

61341

Bone study—whole body and PET, with, when undertaken, blood flow, blood pool and delayed imaging on a separate occasion (R)

600.70

61344

Computed tomography performed at the same time and covering the same body area as positron emission tomography covered by items 61311, 61332, 61333, 61336, 61337 and 61341, for the purpose of anatomic localisation or attenuation correction if no separate diagnostic CT report is issued (R)

100.00

 

Schedule 2 – Closed periods of application

 

Items in Schedule 1 Apply from

Items in Schedule 1 Apply until

14 September 2019

20 December 2019

1 December 2020

28 February 2021

 

Note: Further periods may be specified by a new determination amending Schedule 2 of this principal determination, if, for technical or any other reason, items 61330, 61348, 61307, 61402, 61421 and 61425 in the Diagnostic Imaging Services Table may be unavailable, such that items in Schedule 1 to this determination can instead apply for the period so limited.


Endnotes

Endnote 1—About the endnotes

The endnotes provide information about this compilation and the compiled law.

The following endnotes are included in every compilation:

Endnote 1—About the endnotes

Endnote 2—Abbreviation key

Endnote 3—Legislation history

Endnote 4—Amendment history

Abbreviation key—Endnote 2

The abbreviation key sets out abbreviations that may be used in the endnotes.

Legislation history and amendment history—Endnotes 3 and 4

Amending laws are annotated in the legislation history and amendment history.

The legislation history in endnote 3 provides information about each law that has amended (or will amend) the compiled law. The information includes commencement details for amending laws and details of any application, saving or transitional provisions that are not included in this compilation.

The amendment history in endnote 4 provides information about amendments at the provision (generally section or equivalent) level. It also includes information about any provision of the compiled law that has been repealed in accordance with a provision of the law.

Editorial changes

The Legislation Act 2003 authorises First Parliamentary Counsel to make editorial and presentational changes to a compiled law in preparing a compilation of the law for registration. The changes must not change the effect of the law. Editorial changes take effect from the compilation registration date.

If the compilation includes editorial changes, the endnotes include a brief outline of the changes in general terms. Full details of any changes can be obtained from the Office of Parliamentary Counsel.

Misdescribed amendments

A misdescribed amendment is an amendment that does not accurately describe the amendment to be made. If, despite the misdescription, the amendment can be given effect as intended, the amendment is incorporated into the compiled law and the abbreviation “(md)” added to the details of the amendment included in the amendment history.

If a misdescribed amendment cannot be given effect as intended, the abbreviation “(md not incorp)” is added to the details of the amendment included in the amendment history.

 

Endnote 2—Abbreviation key

 

ad = added or inserted

o = order(s)

am = amended

Ord = Ordinance

amdt = amendment

orig = original

c = clause(s)

par = paragraph(s)/subparagraph(s)

C[x] = Compilation No. x

    /sub‑subparagraph(s)

Ch = Chapter(s)

pres = present

def = definition(s)

prev = previous

Dict = Dictionary

(prev…) = previously

disallowed = disallowed by Parliament

Pt = Part(s)

Div = Division(s)

r = regulation(s)/rule(s)

ed = editorial change

reloc = relocated

exp = expires/expired or ceases/ceased to have

renum = renumbered

    effect

rep = repealed

F = Federal Register of Legislation

rs = repealed and substituted

gaz = gazette

s = section(s)/subsection(s)

LA = Legislation Act 2003

Sch = Schedule(s)

LIA = Legislative Instruments Act 2003

Sdiv = Subdivision(s)

(md) = misdescribed amendment can be given

SLI = Select Legislative Instrument

    effect

SR = Statutory Rules

(md not incorp) = misdescribed amendment

Sub‑Ch = Sub‑Chapter(s)

    cannot be given effect

SubPt = Subpart(s)

mod = modified/modification

underlining = whole or part not

No. = Number(s)

    commenced or to be commenced

 

Endnote 3—Legislation history

 

Name

Registration

Commencement

Application, saving and transitional provisions

Health Insurance (Section 3C Diagnostic Imaging – Nuclear Medicine Services) Determination 2019

14 Sep 2019 (F2019L01195)

14 Sep 2019 (s 2(1) item 1)

 

Health Insurance (Section 3C Diagnostic Imaging – Nuclear Medicine Services) Amendment Determination 2019

4 Oct 2019 (F2019L01309)

14 Sep 2019 (s 2(1) item 1)

Health Insurance (Section 3C Diagnostic Imaging – Nuclear Medicine Services) Amendment (No. 2) Determination 2019

19 Dec 2019

(F2019L01668)

20 Dec 2019 (s 2)

Health Insurance (Section 3C Diagnostic Imaging – Nuclear Medicine Services) Amendment Determination 2020

1 Dec 2020 (F2020L01513)

1 Dec 2020 (s 2(1) item 1)

 

Endnote 4—Amendment history

 

Provision affected

How affected

s 2....................................................

rep LA s 48D

s 4....................................................

am F2020L01513

s 6....................................................

am F2019L01309

s 7....................................................

ad F2019L01668

Schedule 1

 

Schedule 1.......................................

am F2019L01309; F2020L01513

Schedule 2

 

Schedule 2.......................................

ad F2019L01668

 

am F2020L01513