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This instrument provides the legal basis for Medicare Benefits Schedule items (63501, 63502, 63504, 63505, 63498 and 63499) to patients who have, or are suspected of having, breast implants manufactured Poly Implant Prosthese implants (PIP implants).
Administered by: Health
Registered 29 Apr 2020
Tabling HistoryDate
Tabled HR12-May-2020
Tabled Senate12-May-2020
Table of contents.

Commonwealth Coat of Arms of Australia

 

Health Insurance (Poly Implant Prosthese MRI) Determination 2020

I, David Weiss, delegate of the Minister for Health, make the following determination.

Dated        24 April 2020

 

 

 

 

 

David Weiss

First Assistant Secretary

Medical Benefits Division

Health Financing Group

Department of Health

 

 

 

 

 

  

  


Contents

1  Name........................................................................................................................................ 1

2  Commencement........................................................................................................................ 1

3  Authority.................................................................................................................................. 1

4  Definitions................................................................................................................................ 1

5  Treatment of relevant services.................................................................................................. 2

6  Specification of relevant services.............................................................................................. 3

Schedule – relevant services                                                                                         5

 


1  Name

              This instrument is the Health Insurance (Poly Implant Prosthese MRI) Determination 2020.

2  Commencement

(1)          Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.

 

Commencement information

Column 1

Column 2

Column 3

Provisions

Commencement

Date/Details

1.  The whole of this instrument

1 May 2020

 

                Note:        This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.

(2)       Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.

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.

MRI means magnetic resonance imaging.

PIP implant means a silicone breast prosthesis manufactured by Poly Implant Prosthese.

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, other than clause 1.2.21 of the diagnostic imaging services table.

Note   Clause 1.2.21 of the diagnostic imaging services table sets out the ‘multiple services rule’, which provides for reductions in the fees for diagnostic imaging services where multiple services are provided to the same patient on the same day, for example 2 or more diagnostic imaging services or one or more R-type diagnostic imaging service and one or more consultation service.  The exclusion of clause 1.2.21 means that the services in the Determination will not be relevant in the application of the multiple services rule.

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

remote location means a place within Australia that is more than 30 kilometres by road from:

                (a)    a hospital that provides a radiology or computed tomography service under the direction of a specialist in the specialty of diagnostic radiology; or

               (b)    a free‑standing radiology or computed tomography facility under the direction of a specialist in the specialty of diagnostic radiology.

Schedule means a 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;

·         medical practitioner;

·         professional service’ and

·         specialist.

 (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 that provision 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

(1)     For subsection 3C(1) of the Act, a relevant service in Part 1 of the Schedule, provided in accordance with this instrument and as a clinically relevant service, is to be treated, for the relevant provisions, as if:

(a)                    it were both a professional service and a diagnostic imaging service; and

(b)                   there were an item in Group I5 of 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.

(2)     For subsection 3C(1) of the Act, a relevant service in Part 2 of the Schedule, provided in accordance with this instrument and as a clinically relvant service, is to be treated, for the relevant provisions, as if:

                (a)    it were both a professional service and a diagnostic imaging service; and

               (b)    there were an item in Subgroup 22 of Group I5 of the diagnostic imaging services table that:

                          (i)    related to the service; and

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

Note   For this Determination, an internal Territory is deemed to form part of the State of New South Wales — see subsection 3C (7) of the Act.

 

6  Specification of relevant services

(1)     Paragraph 1.2.19(1)(a) of the diagnostic imaging services table shall be taken to have effect as if the relevant services were also specified in that paragraph.

(2)     Clause 2.5.7 of the diagnostic imaging services table shall be taken to have effect as if the items in Part 1 of the Schedule were also specified in that clause.

7  Supervision and reporting of relevant services

          An item in Part 1 and Part 2 of the Schedule applies only to a service:

                (a)    both:

                        (i)         performed under the professional supervision of a specialist in

                        diagnostic radiology who is available to monitor and influence the conduct and diagnostic quality of the examination, including, if necessary, by personal attendance on the patient; and

                        (ii)        reported by a specialist in diagnostic radiology; or

                (b)    performed:

                        (i)         in an emergency; or

                        (ii)        because of medical necessity, in a remote location.

8  Requests for relevant services

(1)     An item in Part 1 and Part 2 of the Schedule applies only to a service provided at the request of a medical practitioner.

(2)     A request must be in writing and specify:

(a)      that the patient is a person who has or is suspected of having a PIP implant; and

(b)     whether the patient displays symptoms indicating that the implant has or may have ruptured.

9  Limitation on number of services 

          Items 63501 and 63502 do not apply to the service described in the item if a patient has been provided with the service described in either item in the previous 24 months. 


 

10  Modifying items 63498 and 63499

 

(1)     Subject to subsections (2), (3) and (4), if item 63498 or 63499 applies to a service in this instrument, the fee specified in the item applies in addition to the fee specified in the other item in this instrument that applies to the service.

 

(2)     If 2 or more services described in item 63498 are performed for a person on the same day, the fee specified in that item applies to one of those services only.

 

(3)     If 2 or more services described in item 63499 are performed for a person on the same day, the fee specified in that item applies to one of those services only.

 

(4)     If:

                (a)    one or more services described in item 63498; and

               (b)    one or more services described in item 63499;

are performed for a person on the same day, the fee specified in item 63498 or item 63499, but not both those items, applies to one of those services only.


 

Schedule – relevant services

Part 1

 

Group I5 – Magnetic Resonance Imaging

 

Subgroup 32 – Magnetic resonance imaging – PIP breast implant

 

Item

Service

Fee ($)

63501

MRI – scan of one or both breasts for the evaluation of implant integrity where:

(a) a dedicated breast coil is used; and

(b) the request for the scan identifies that the patient:

(i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and

(ii) the result of the scan confirms a loss of integrity of the implant (R)

500.00

63502

MRI – scan of one or both breasts for the evaluation of implant integrity where:

(a) a dedicated breast coil is used; and

(b) the request for the scan identifies that the patient:

(i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and

(ii) the result of the scan does not demonstrate a loss of integrity of the implant (R)

500.00

63504

MRI – scan of one or both breasts for the evaluation of implant integrity where:

(a) a dedicated breast coil is used; and

(b) the request for the scan identifies that the patient:

(i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and

(ii) presents with symptoms where implant rupture is suspected; and

(iii) the result of the scan confirms a loss of integrity of the implant (R)

500.00

63505

MRI – scan of one or both breasts for the evaluation of implant integrity where:

(a) a dedicated breast coil is used; and

(b) the request for the scan identifies that the patient:

(i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and

(ii) presents with symptoms where implant rupture is suspected; and

(iii) the result of the scan does not demonstrate a loss of integrity of the implant (R)

500.00

 

Part 2

 

Group I5 – Magnetic Resonance Imaging

Subgroup 22 – Modifying items

Item

Service

Fee ($)

63498

MRI service to which item 63501, 63502, 63504 or 63505 applies if the service is performed on a person using intravenous or intra muscular sedation

44.80

63499

MRI service to which item 63501, 63502, 63504 or 63505 applies if  the service is performed on a person under anaesthetic in the presence of a medical practitioner who is qualified to perform an anaesthetic

156.80