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Determinations/Health as made
This instrument amends the Health Insurance (Section 3C Diagnostic Imaging – Nuclear Medicine Services) Determination 2019 to reinstate the substitute items from 1 December 2020 until 28 February 2021, and to amend two existing substitute items and introduce five new substitute items to align with cardiac services.
Administered by: Health
General Comments: This instrument was registered at 9:23am (by legal time in the Australian Capital Territory) on 1 December 2020.
Registered 01 Dec 2020
Tabling HistoryDate
Tabled HR02-Dec-2020
Tabled Senate03-Dec-2020
To be repealed 26 Feb 2021
Repealed by Division 1 of Part 3 of Chapter 3 of the Legislation Act 2003
Table of contents.

Commonwealth Coat of Arms of Australia

 

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

I, Paul McBride, delegate of the Minister for Health, make the following Determination.

Dated               30 November 2020

Paul McBride

First Assistant Secretary

Medical Benefits Division

Health Resourcing Group

Department of Health

 

 

 


Contents

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

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

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

4  Schedules................................................................................................................................. 1

Schedule 1— Amendments................................................................................................... 1

Health Insurance (Section 3C Diagnostic Imaging – Nuclear Medicine Services) Determination 2019            1

 

 


1  Name

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

Immediately after registration

 

                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  Schedules

                        Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.


 

Schedule 1— Amendments

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

1 Section 4 (after definition of Act)

Insert:

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.

2 Schedule 1 (above the table)

Insert:

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.

 

3 Schedule 1 (table)

Repeal the table, substitute:

 

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

 

4 Schedule 2 (table)

Repeal the table, substitute:

 

Items in Schedule 1 Apply from

Items in Schedule 1  Apply until

14 September 2019

20 December 2019

1 December 2020

28 February 2021