Health Insurance Legislation Amendment (2021 Measures No. 2) Regulations 2021 (Cth)

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Health Insurance Legislation Amendment (2021 Measures No. 2) Regulations 2021

I, General the Honourable David Hurley AC DSC (Retd), Governor‑General of the Commonwealth of Australia, acting with the advice of the Federal Executive Council, make the following regulations.

Dated 16 September 2021

David Hurley

Governor‑General

By His Excellency’s Command

Greg Hunt

Minister for Health and Aged Care

Contents

1Name

This instrument is the Health Insurance Legislation Amendment (2021 Measures No. 2) Regulations 2021.

2Commencement
  1. (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 November 2021.

1 November 2021

Note: This table relates only to the provisions of this instrument as originally made.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.

  1. (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.

3Authority

This instrument is made under the Health Insurance Act 1973.

4Schedules

Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.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

Part 1Repetitive transcranial magnetic stimulation

Health Insurance (General Medical Services Table) Regulations 2021

1

Subclause 1.2.11(1) of Schedule 1

Omit “14218”, substitute “14217, 14218, 14220”.

2

After clause 5.2.6 of Schedule 1

Insert:

5.2.6ARestriction on items 14217 and 14220—maintenance therapy

A service under item 14217 or 14220 cannot be provided to a patient as maintenance therapy for the prevention of further relapse of the patient’s depression.

3

Schedule 1 (after item 14212)

Insert:

14216

Professional attendance on a patient by a psychiatrist, who has undertaken training in Repetitive Transcranial Magnetic Stimulation (rTMS), for treatment mapping for rTMS, if the patient:

(a) has not previously received any prior transcranial magnetic stimulation therapy in a public or private setting; and

(b) is at least 18 years old; and

(c) is diagnosed with a major depressive episode; and

(d) has failed to receive satisfactory improvement for the major depressive episode despite the adequate trialling of at least 2 different classes of antidepressant medications, unless contraindicated, and all of the following apply:

(i) the patient’s adherence to antidepressant treatment has been formally assessed;

(ii) the trialling of each antidepressant medication has been at the recommended therapeutic dose for a minimum of 3 weeks;

(iii) where clinically appropriate, the treatment has been titrated to the maximum tolerated therapeutic dose; and

(e) has undertaken psychological therapy, if clinically appropriate

186.40

14217

Repetitive Transcranial Magnetic Stimulation (rTMS) treatment of up to 35 services provided by, or on behalf of, a psychiatrist who has undertaken training in rTMS, if the patient has previously received a service under item 14216— each service up to 35 services

160.00

4

Schedule 1 (after item 14218)

Insert:

14219

Professional attendance on a patient by a psychiatrist, who has undertaken training in Repetitive Transcranial Magnetic Stimulation (rTMS), for treatment mapping for rTMS, if the patient:

(a) is at least 18 years old; and

(b) is diagnosed with a major depressive episode; and

(c) has failed to receive satisfactory improvement for the major depressive episode despite the adequate trialling of at least 2 different classes of antidepressant medications, unless contraindicated, and all of the following apply:

(i) the patient’s adherence to antidepressant treatment has been formally assessed;

(ii) the trialling of each antidepressant medication has been at the recommended therapeutic dose for a minimum of 3 weeks;

(iii) where clinically appropriate, the treatment has been titrated to the maximum tolerated therapeutic dose; and

(d) has undertaken psychological therapy, if clinically appropriate; and

(e) has previously received an initial service under item 14217 and the patient:

(i) has relapsed after a remission following the initial service; and

(ii) has had a satisfactory clinical response to the service under item 14217 (which has been assessed by a validated major depressive disorder tool at least 4 months after receiving that service)

186.40

14220

Repetitive Transcranial Magnetic Stimulation (rTMS) treatment of up to 15 services provided by, or on behalf of, a psychiatrist who has undertaken training in rTMS, if the patient has previously received:

(a) a service under item 14217 (which was not provided in the previous 4 months); and

(b) a service under item 14219

Each service up to 15 services

160.00

Part 2Sentinel lymph node biopsy

Health Insurance (General Medical Services Table) Regulations 2021

5

Clause 5.10.4 of Schedule 1 (heading)

Omit “and 30300”, substitute “, 30300 and 30311”.

6

Clause 5.10.4 of Schedule 1

Omit “or 30300”, substitute “, 30300 or 30311”.

7

Clause 5.10.4 of Schedule 1

Omit “lymphotrophic”, substitute “lymphotropic”.

8

Schedule 1 (after item 30310)

Insert:

30311

Sentinel lymph node biopsy or biopsies for cutaneous melanoma, using preoperative lymphoscintigraphy and lymphotropic dye injection, if:

(a) the primary lesion is greater than 1.0 mm in depth (or at least 0.8 mm in depth in the presence of ulceration); and

(b) appropriate excision of the primary melanoma has occurred; and

(c) the service is not associated with a service to which item 30075, 30078, 30299, 30300, 30302, 30303, 30329, 30332, 30618, 30820, 31423, 52025 or 52027 applies

Applicable to only one lesion per occasion on which the service is provided (H) (Anaes.) (Assist.)

647.65

Part 3Thoracic medicine

Health Insurance (General Medical Services Table) Regulations 2021

  1. 9

    Schedule 1 (item 11503, column 2, paragraph (b))

Omit “consultant respiratory physician”, substitute “specialist or consultant physician”.

  1. 10

    Schedule 1 (item 11508, column 2, paragraph (f))

Omit “consultant respiratory physician”, substitute “specialist or consultant physician”.

  1. 11

    Schedule 1 (item 11512, column 2, paragraph (d))

Omit “consultant physician practising respiratory medicine”, substitute “specialist or consultant physician”.

Part 4Dermatology

Health Insurance (General Medical Services Table) Regulations 2021

12

Schedule 1 (item 30210, column 2)

Omit “on a patient less than 16 years of age”.

Part 5Endoscopic mucosal resection

Health Insurance (General Medical Services Table) Regulations 2021

  1. 13

    Schedule 1 (at the end of Subgroup 2 of Group T8)

Add:

32230

Endoscopic mucosal resection using electrocautery of a non‑invasive sessile or flat superficial colorectal neoplasm which is at least 25mm in diameter, if the service is:

(a) provided by a specialist gastroenterologist or surgical endoscopist; and

(b) supported by photographic evidence to confirm the size of the polyp in situ, and

(c) performed in association with a service to which item 32222, 32223, 32224, 32225, 32226 or 32228 applies.

Applicable only once per polyp (H) (Anaes.)

695.25

Part 6Vertebroplasty

Health Insurance (General Medical Services Table) Regulations 2021

14

Schedule 1 (after item 35363)

Insert:

35401

Vertebroplasty, for one or more fractures in one or more vertebrae, performed by an interventional radiologist, for the treatment of a painful osteoporotic thoracolumbar vertebral compression fracture of the thoracolumbar spinal segment (T11, T12, L1 or L2), if:

(a) pain is severe (numeric rated pain score greater than or equal to 7 out of 10); and

(b) symptoms are poorly controlled by opiate therapy; and

(c) severe pain duration is 3 weeks or less; and

(d) there is MRI (or SPECT‑CT if MRI unavailable) evidence of acute vertebral fracture

Applicable only once for the same fracture, but is applicable for a new fracture of the same vertebra or vertebrae (H) (Anaes.)

710.50

  1. 15

    Clause 7.1.1 of Schedule 1 (paragraph (o) of the definition of non‑medicare service)

Repeal the paragraph.

Part 7Autologous fat grafting

Health Insurance (General Medical Services Table) Regulations 2021

16

Schedule 1 (after item 45533)

Insert:

45534

Autologous fat grafting, unilateral service (harvesting, preparation and injection of adipocytes) if:

(a) the autologous fat grafting is for one or more of the following purposes:

(i) the correction of defects arising from treatment and prevention of breast cancer in patients with contour defects, greater than or equal to 20% volume asymmetry, post‑treatment pain or poor prosthetic coverage;

(ii) the preparation of post mastectomy thin or irradiated skin flaps in patients intending to have breast reconstruction;

(iii) breast reconstruction in breast cancer patients;

(iv) the correction of developmental disorders of the breast; and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

Up to a total of 4 services per side (for total treatment of a single breast) (H) (Anaes.)

651.50

45535

Autologous fat grafting, bilateral service (harvesting, preparation and injection of adipocytes) if:

(a) the autologous fat grafting is for one or more of the following purposes:

(i) the correction of defects arising from treatment and prevention of breast cancer in patients with contour defects, greater than or equal to 20% volume asymmetry, post‑treatment pain or poor prosthetic coverage;

(ii) the preparation of post mastectomy thin or irradiated skin flaps in patients intending to have breast reconstruction;

(iii) breast reconstruction in breast cancer patients;

(iv) the correction of developmental disorders of the breast; and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

Up to a total of 4 services (H) (Anaes.)

1,140.15

17

Schedule 1 (after item 45588)

Insert:

45589

Autologous fat grafting (harvesting, preparation and injection of adipocytes) if:

(a) the autologous fat grafting is for either or both of the following purposes:

(i) the correction of asymmetry arising from volume and contour defects in craniofacial disorders—up to a total of 4 services if each service is provided at least 3 months after the previous service;

(ii) the treatment of burn scar or associated skin graft in the context of scar contracture, contour deformity or neuropathic pain, for patients who have undergone a minimum of 3 months of topical therapies, including silicone and pressure therapy, with an unsatisfactory or minimal level of improvement—up to a total of 4 services per region of the body (upper or lower limbs, trunk, neck or face) if each service provided per region of the body is provided at least 3 months after the previous such service; and

(b) both:

(i) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes; and

(ii) for craniofacial disorders, evidence of diagnosis of the qualifying craniofacial disorder is documented in the patient notes

(H) (Anaes.)

651.50

Part 8Breast ptosis

Health Insurance (General Medical Services Table) Regulations 2021

18

Schedule 1 (cell at item 45558, column 2)

Repeal the cell, substitute:

Correction of bilateral breast ptosis by mastopexy, if:

(a) at least two‑thirds of the breast tissue, including the nipple, lies inferior to the inframammary fold where the nipple is located at the most dependent, inferior part of the breast contour; and

(b) photographic evidence (including anterior, left lateral and right lateral views), with a marker at the level of the inframammary fold, demonstrating the clinical need for this service, is documented in the patient notes

Applicable only once per lifetime (H) (Anaes.) (Assist.)

Part 9Ambulatory blood pressure monitoring

Health Insurance (General Medical Services Table) Regulations 2021

19

Subclause 1.2.11(1) of Schedule 1

After “11605,”, insert “11607,”.

20

Schedule 1 (after item 11605)

Insert:

11607

Continuous ambulatory blood pressure recording for 24 hours or more for a patient if:

(a) the patient has a clinic blood pressure measurement (using a sphygmomanometer or a validated oscillometric blood pressure monitoring device) of either or both of the following measurements:

(i) systolic blood pressure greater than or equal to 140 mmHg and less than or equal to 180 mmHg;

(ii) diastolic blood pressure greater than or equal to 90 mmHg and less than or equal to 110 mmHg; and

(b) the patient has not commenced anti‑hypertensive therapy; and

(c) the recording includes the patient’s resting blood pressure; and

(d) the recording is conducted using microprocessor‑based analysis equipment; and

(e) the recording is interpreted by a medical practitioner and a report is prepared by the same medical practitioner; and

(f) a treatment plan is provided for the patient; and

(g) the service:

(i) is not provided in association with ambulatory electrocardiogram recording, and

(ii) is not associated with a service to which any of the following items apply:

(A) 177;

(B) 224 to 228;

(C) 229 to 244;

(D) 699;

(E) 701 to 707;

(F) 721 to 732;

(G) 735 to 758.

Applicable only once in any 12 month period

Note: Items 177, 224 to 228, 229 to 244 and 699 are specified in determinations made under subsection 3C(1) of the Act.

107.20

Part 10Varicose vein treatment

Health Insurance (General Medical Services Table) Regulations 2021

21

Schedule 1 (item 32500)

Repeal the item, substitute:

32500

Varicose veins, multiple injections of sclerosant using continuous compression techniques, including associated consultation, one or both legs, if:

(a) proximal reflux of 0.5 seconds or longer has been demonstrated; and

(b) the service is not for cosmetic purposes; and

(c) the service is not associated with:

(i) any other varicose vein operation on the same leg (excluding aftercare); or

(ii) a service on the same leg (excluding aftercare) to which any of the following items apply:

(A) 35200;

(B) 59970 to 60078;

(C) 60500 to 60509;

(D) 61109

Applicable to a maximum of 6 treatments in a 12 month period (Anaes.)

114.20

22

Schedule 1 (items 32507 to 32529)

Repeal the items, substitute:

32507

Varicose veins, sub‑fascial ligation of one or more incompetent perforating veins in one leg of a patient, if the service:

(a) is performed by open surgical technique (not including endoscopic ligation) and the patient has significant signs or symptoms (including one or more of the following signs or symptoms) attributable to venous reflux:

(i) ache;

(ii) pain;

(iii) tightness;

(iv) skin irritation;

(v) heaviness;

(vi) muscle cramps;

(vii) limb swelling;

(viii) discolouration;

(ix) discomfort;

(x) any other signs or symptoms attributable to venous dysfunction; and

(b) is not associated with:

(i) any other varicose vein operation on the same leg; or

(ii) a service (on the same leg) to which item 35200, 60072, 60075 or 60078 applies

(H) (Anaes.) (Assist.)

555.25

32508

Varicose veins, complete dissection at the sapheno‑femoral or sapheno‑popliteal junction, with or without either ligation or stripping, or both, of the great or small saphenous veins in one leg of a patient, for the first time on the same leg, including excision or injection of either tributaries or incompetent perforating veins, or both, if the patient has significant signs or symptoms (including one or more of the following signs or symptoms) attributable to venous reflux:

(a) ache;

(b) pain;

(c) tightness;

(d) skin irritation;

(e) heaviness;

(f) muscle cramps;

(g) limb swelling;

(h) discolouration;

(i) discomfort;

(j) any other signs or symptoms attributable to venous dysfunction

(H) (Anaes.) (Assist.)

555.25

32511

Varicose veins, complete dissection at the sapheno‑femoral and sapheno‑popliteal junction, with or without either ligation or stripping, or both, of the great or small saphenous veins in one leg of a patient, for the first time on the same leg, including excision or injection of either tributaries or incompetent perforating veins, or both, if the patient has significant signs or symptoms (including one or more of the following signs or symptoms) attributable to venous reflux:

(a) ache;

(b) pain;

(c) tightness;

(d) skin irritation;

(e) heaviness;

(f) muscle cramps;

(g) limb swelling;

(h) discolouration;

(i) discomfort;

(j) any other signs or symptoms attributable to venous dysfunction

(H) (Anaes.) (Assist.)

825.45

32514

Varicose veins, ligation of the great or small saphenous vein in the same leg of a patient, with or without stripping, by re‑operation for recurrent veins in the same territory—one leg—including excision or injection of either tributaries or incompetent perforating veins, or both, if the patient has significant signs or symptoms (including one or more of the following signs or symptoms) attributable to venous reflux:

(a) ache;

(b) pain;

(c) tightness;

(d) skin irritation;

(e) heaviness;

(f) muscle cramps;

(g) limb swelling;

(h) discolouration;

(i) discomfort;

(j) any other signs or symptoms attributable to venous dysfunction

(H) (Anaes.) (Assist.)

964.35

32517

Varicose veins, ligation of the great and small saphenous vein in the same leg of a patient, with or without stripping, by re‑operation for recurrent veins in either territory—one leg—including excision or injection of either tributaries or incompetent perforating veins, or both, if the patient has significant signs or symptoms (including one or more of the following signs or symptoms) attributable to venous reflux:

(a) ache;

(b) pain;

(c) tightness;

(d) skin irritation;

(e) heaviness;

(f) muscle cramps;

(g) limb swelling;

(h) discolouration;

(i) discomfort;

(j) any other signs or symptoms attributable to venous dysfunction

(H) (Anaes.) (Assist.)

1,241.80

32520

Varicose veins, abolition of venous reflux by occlusion of a primary or recurrent great or small saphenous vein (and major tributaries of saphenous veins as necessary) in one leg of a patient, using a laser probe introduced by an endovenous catheter, if all of the following apply:

(a) it is documented by duplex ultrasound that the great or small saphenous vein (whichever is to be treated) of the patient demonstrates reflux of 0.5 seconds or longer;

(b) the patient has significant signs or symptoms (including one or more of the following signs or symptoms) attributable to venous reflux:

(i) ache;

(ii) pain;

(iii) tightness;

(iv) skin irritation;

(v) heaviness;

(vi) muscle cramps;

(vii) limb swelling;

(viii) discolouration;

(ix) discomfort;

(x) any other signs or symptoms attributable to venous dysfunction;

(c) the service does not include radiofrequency diathermy, radiofrequency ablation or cyanoacrylate adhesive;

(d) the service is not associated with a service (on the same leg) to which any of the following items apply:

(i) 32500 to 32507;

(ii) 35200;

(iii) 59970 to 60078;

(iv) 60500 to 60509;

(v) 61109

The service includes all preparation and immediate clinical aftercare (including excision or injection of either tributaries or incompetent perforating veins, or both)

(Anaes.)

555.25

32522

Varicose veins, abolition of venous reflux by occlusion of a primary or recurrent great and small saphenous vein (and major tributaries of saphenous veins as necessary) in one leg of a patient, using a laser probe introduced by an endovenous catheter, if all of the following apply:

(a) it is documented by duplex ultrasound that the great and small saphenous veins of the patient demonstrate reflux of 0.5 seconds or longer;

(b) the patient has significant signs or symptoms (including one or more of the following signs or symptoms) attributable to venous reflux:

(i) ache;

(ii) pain;

(iii) tightness;

(iv) skin irritation;

(v) heaviness;

(vi) muscle cramps;

(vii) limb swelling;

(viii) discolouration;

(ix) discomfort;

(x) any other signs or symptoms attributable to venous dysfunction;

(c) the service does not include radiofrequency diathermy, radiofrequency ablation or cyanoacrylate adhesive;

(d) the service is not associated with a service (on the same leg) to which any of the following items apply:

(i) 32500 to 32507;

(ii) 35200;

(iii) 59970 to 60078;

(iv) 60500 to 60509;

(v) 61109

The service includes all preparation and immediate clinical aftercare (including excision or injection of either tributaries or incompetent perforating veins, or both)

(Anaes.)

825.45

32523

Varicose veins, abolition of venous reflux by occlusion of a primary or recurrent great or small saphenous vein (and major tributaries of saphenous veins as necessary) in one leg of a patient, using a radiofrequency catheter introduced by an endovenous catheter, if all of the following apply:

(a) it is documented by duplex ultrasound that the great or small saphenous vein (whichever is to be treated) demonstrates reflux of 0.5 seconds or longer;

(b) the patient has significant signs or symptoms (including one or more of the following signs or symptoms) attributable to venous reflux:

(i) ache;

(ii) pain;

(iii) tightness;

(iv) skin irritation;

(v) heaviness;

(vi) muscle cramps;

(vii) limb swelling;

(viii) discolouration;

(ix) discomfort;

(x) any other signs or symptoms attributable to venous dysfunction;

(c) the service does not include endovenous laser therapy or cyanoacrylate adhesive;

(d) the service is not associated with a service (on the same leg) to which any of the following items apply:

(i) 32500 to 32507;

(ii) 35200;

(iii) 59970 to 60078;

(iv) 60500 to 60509;

(v) 61109

The service includes all preparation and immediate clinical aftercare (including excision or injection of either tributaries or incompetent perforating veins, or both)

(Anaes.)

555.25

32526

Varicose veins, abolition of venous reflux by occlusion of a primary or recurrent great and small saphenous vein (and major tributaries of saphenous veins as necessary) in one leg of a patient, using a radiofrequency catheter introduced by an endovenous catheter, if all of the following apply:

(a) it is documented by duplex ultrasound that the great and small saphenous veins demonstrate reflux of 0.5 seconds or longer;

(b) the patient has significant signs or symptoms (including one or more of the following signs or symptoms) attributable to venous reflux:

(i) ache;

(ii) pain;

(iii) tightness;

(iv) skin irritation;

(v) heaviness;

(vi) muscle cramps;

(vii) limb swelling;

(viii) discolouration;

(ix) discomfort;

(x) any other signs or symptoms attributable to venous dysfunction;

(c) the service does not include endovenous laser therapy or cyanoacrylate adhesive;

(d) the service is not associated with a service (on the same leg) to which any of the following items apply:

(i) 32500 to 32507;

(ii) 35200;

(iii) 59970 to 60078;

(iv) 60500 to 60509;

(v) 61109

The service includes all preparation and immediate clinical aftercare (including excision or injection of either tributaries or incompetent perforating veins, or both)

(Anaes.)

825.45

32528

Varicose veins, abolition of venous reflux by occlusion of a primary or recurrent great or small saphenous vein (and major tributaries of saphenous veins as necessary) in one leg of a patient, using cyanoacrylate adhesive, if all of the following apply:

(a) it is documented by duplex ultrasound that the great or small saphenous vein (whichever is to be treated) demonstrates reflux of 0.5 seconds or longer;

(b) the patient has significant signs or symptoms (including one or more of the following signs or symptoms) attributable to venous reflux:

(i) ache;

(ii) pain;

(iii) tightness;

(iv) skin irritation;

(v) heaviness;

(vi) muscle cramps;

(vii) limb swelling;

(viii) discolouration;

(ix) discomfort;

(x) any other signs or symptoms attributable to venous dysfunction;

(c) the service does not include radiofrequency diathermy, radiofrequency ablation or endovenous laser therapy;

(d) the service is not associated with a service (on the same leg) to which any of the following items apply:

(i) 32500 to 32507;

(ii) 35200;

(iii) 59970 to 60078;

(iv) 60500 to 60509;

(v) 61109

The service include all preparation and immediate clinical aftercare (including excision or injection of either tributaries or incompetent perforating veins, or both)

(Anaes.)

555.25

32529

Varicose veins, abolition of venous reflux by occlusion of a primary or recurrent great and small saphenous vein (and major tributaries of saphenous veins as necessary) in one leg of a patient, using cyanoacrylate adhesive, if all of the following apply:

(a) it is documented by duplex ultrasound that the great and small saphenous veins demonstrate reflux of 0.5 seconds or longer;

(b) the patient has significant signs or symptoms (including one or more of the following signs or symptoms) attributable to venous reflux:

(i) ache;

(ii) pain;

(iii) tightness;

(iv) skin irritation;

(v) heaviness;

(vi) muscle cramps;

(vii) limb swelling;

(viii) discolouration;

(ix) discomfort;

(x) any other signs or symptoms attributable to venous dysfunction;

(c) the service does not include radiofrequency diathermy, radiofrequency ablation or endovenous laser therapy;

(d) the service is not associated with a service (on the same leg) to which any of the following items apply:

(i) 32500 to 32507;

(ii) 35200;

(iii) 59970 to 60078;

(iv) 60500 to 60509;

(v) 61109

The service includes all preparation and immediate clinical aftercare (including excision or injection of either tributaries or incompetent perforating veins, or both)

(Anaes.)

825.45

Part 11Co‑claiming restrictions

Health Insurance (General Medical Services Table) Regulations 2021

23

At the end of clause 1.2.3 of Schedule 1

Add:

  1. (3)

    The item also does not apply to an attendance on a patient if the attendance is in association with a service to which an item in Group I5 of the diagnostic imaging services table applies, unless the practitioner providing the service considers the attendance is necessary for the management or treatment of the patient.

Part 12Preimplantation embryo biopsy

Health Insurance (General Medical Services Table) Regulations 2021

24

Schedule 1 (after item 13206)

Insert:

13207

Biopsy of an embryo, from a patient who is eligible for a service described in item 73384 under clause 2.7.3A of the pathology services table, for the purpose of providing a sample for pre‑implantation genetic testing—applicable to one or more tests performed in one assisted reproductive treatment cycle

115.00

Part 13Bronchoscopy with dilatation of tracheal stricture

Health Insurance (General Medical Services Table) Regulations 2021

25

Schedule 1 (after item 38427)

Insert:

38428

Bronchoscopy with dilatation of tracheal stricture (Anaes.)

256.50

26

Schedule 1 (item 41904)

Repeal the item.

Part 14Partial rhinoplasty

Health Insurance (General Medical Services Table) Regulations 2021

27

Schedule 1 (item 45632, column 2)

Omit “correction of lateral or alar cartilages”, substitute “correction of one or both lateral cartilages, one or both alar cartilages or one or both lateral cartilages and alar cartilages”.

Part 15Spinal decompression

Health Insurance (General Medical Services Table) Regulations 2021

28

Schedule 1 (items 51011 to 51015, column 2)

Omit “Spinal decompression or exposure via partial or total laminectomy, partial vertebrectomy or posterior spinal release”, substitute “Direct spinal decompression or exposure (via a partial or a total laminectomy or a partial vertebrectomy), or a posterior spinal release”.

Part 16Anterior and posterior pelvic ring disruption

Health Insurance (General Medical Services Table) Regulations 2021

29

Schedule 1 (after item 47489)

Insert:

47491

Combined anterior and posterior pelvic ring disruption, including sacroiliac joint disruption, treatment of fracture by open reduction and internal fixation of both anterior and posterior ring segments

(H) (Anaes.) (Assist.)

1,616.30

Part 17Miscellaneous amendments

Health Insurance (General Medical Services Table) Regulations 2021

30

Schedule 1 (item 35638, column 2)

Omit “30393”, substitute “30724”.

31

Schedule 1 (item 38212, column 2)

Omit “involving 4 or more catheters”.

  1. 32

    Schedule 1 (item 38212, column 2, paragraph (a))

Repeal the paragraph, substitute:

(a) the investigation of supraventricular tachycardia involving 4 or more catheters; or

33

Schedule 1 (items 38727 and 38730)

Omit “38712,”.

34

Schedule 1 (items 45720 to 45752, column 2)

Omit “, excluding services to which item 47933 or 47936 applies”.

35

Schedule 1 (item 46486, column 2)

Before “nail”, insert “acute”.

36

Schedule 1 (item 46498, column 2)

Omit “30106, 30107 or 46363 applies (Anaes.)”, substitute “30107 or 46363 applies (Anaes.) (Assist.)”.

37

Schedule 1 (item 46500, column 2)

Omit “30106 or”.

38

Schedule 1 (item 46501, column 2)

Omit “30106,”.

39

Schedule 1 (item 46503, column 2)

Omit “30106 or”.

40

Schedule 1 (item 46534, column 2)

Omit “(Anaes.)”, substitute “(Anaes.) (Assist.)”.

41

Schedule 1 (item 47450, column 2)

After “external”, insert “fixation”.

42

Schedule 1 (item 48958, column 2)

Omit “attachment”, substitute “reattachment”.

43

Schedule 1 (item 49776, column 2)

Omit “applies”, substitute “applies—may only be claimed once per joint”.

44

Schedule 1 (items 49833 to 49838, column 2)

Omit “hallus”, substitute “hallux”.

45

Schedule 1 (item 50224, column 2)

Omit “or bone”, insert “or aggressive bone”.

Schedule 2Diagnostic imaging servicesPart 1Ultrasound

Health Insurance (Diagnostic Imaging Services Table) Regulations (No. 2) 2020

1

Schedule 1 (items 55065 and 55068, column 2)

After “an item”, insert “(other than item 55736 or 55739)”.

Part 2Computed tomography (examination)

Health Insurance (Diagnostic Imaging Services Table) Regulations (No. 2) 2020

  1. 2

    Schedule 1 (item 56553, column 2, paragraphs (b) and (c))

Repeal the paragraphs, substitute:

(b) the service is not a service to which item 56301, 56307, 56401, 56407, 56409, 56412, 56501, 56507, 56801, 56807 or 57001 applies (R) (Anaes.)

3

Schedule 1 (item 57351)

Repeal the item.

  1. 4

    At the end of Subdivision A of Division 2.2 of Part 2 of Schedule 1

Add:

2.2.5ARestriction on item 57360—patients

Item 57360 does not apply to a service provided to a patient if:

  1. (a)

    in the previous 5 years, a service to which item 57360 or 57364 applies has been provided to the patient; and

  2. (b)

    no obstructive coronary artery disease was detected as part of that service;

unless the patient is:

  1. (c)

    eligible, under clause 5.10.17A of the general medical services table, for a service to which item 38244 or 38247 applies; or

  2. (d)

    eligible, under clause 5.10.17B of the general medical services table, for a service to which item 38248 or 38249 applies.

5

Schedule 1 (cell at item 57360, column 2)

Repeal the cell, substitute:

Computed tomography of the coronary arteries performed on a minimum of a 64 slice (or equivalent) scanner if:

(a) the request is made by a specialist or consultant physician; and

(b) the patient has stable or acute symptoms consistent with coronary ischaemia; and

(c) the patient is at low to intermediate risk of an acute coronary event, including having no significant cardiac biomarker elevation and no electrocardiogram changes indicating acute ischaemia (R) (Anaes.)

Part 3Nuclear medicine imaging

Health Insurance (Diagnostic Imaging Services Table) Regulations (No. 2) 2020

6

Schedule 1 (after item 61559)

Insert:

61560

FDG PET study of the brain, performed for the diagnosis of Alzheimer’s disease, if:

(a) clinical evaluation of the patient by a specialist, or in consultation with a specialist, is equivocal; and

(b) the service includes a quantitative comparison of the results of the study with the results of an FDG PET study of a normal brain from a reference database; and

(c) a service to which this item applies has not been performed on the patient in the previous 12 months; and

(d) a service to which item 61402 applies has not been performed on the patient in the previous 12 months for the diagnosis or management of Alzheimer’s disease

Applicable not more than 3 times per lifetime

605.05

Part 4Magnetic resonance imaging

Health Insurance (Diagnostic Imaging Services Table) Regulations (No. 2) 2020

7

Clause 2.5.8 of Schedule 1

Repeal the clause, substitute:

2.5.8Restriction on items—multiple services in certain subgroups on a day

If an MRI service described in an item in Subgroup 1, 2, 4, 5 or 14 of Group I5, and an MRA service described in an item in Subgroup 3 or 15 of Group I5, are provided to the same patient on the same day, the item in Subgroup 3 or 15 of Group I5 does not apply to the MRA service.

2.5.8ARestriction on items—multiple services in certain subgroups in an attendance

Multiple services in subgroups 1 to 5

  1. (1)

    If more than one service described in an item in Subgroup 1, 2, 3, 4 or 5 of Group I5 is provided to a patient in a single attendance, only the following items apply to the services:

    1. (a)

      the item that describesthe service with the highest fee;

    2. (b)

      each item that describes a service to which subclause (4) applies (if any).

Multiple services in subgroups 6 to 10

  1. (2)

    If more than one service described in an item in Subgroup 6, 7, 8, 9 or 10 of Group I5 is provided to a patient in a single attendance, only the following items apply to the services:

    1. (a)

      the item that describesthe service with the highest fee;

    2. (b)

      each item that describes a service to which subclause (4) applies (if any).

Multiple services with same highest fee

  1. (3)

    For the purposes of paragraphs (1)(a) and (2)(a), if 2 or more applicable fees are equally the highest, only one of those fees is taken to be the highest fee.

Services with documented clinical need

  1. (4)

    For the purposes of paragraphs (1)(b) and (2)(b), this subclause applies to a service provided to a person in an attendance if the clinical need for the service is:

    1. (a)

      stated in the request for the service; and

    2. (b)

      appropriately documented in the record of the service.

2.5.8BReduction in fees—multiple services on same day—Subgroups 12 and 13

  1. (1)

    If a medical practitioner provides 2 or more MRI services described in Subgroup 12 or 13 of Group I5 for the same person on the same day, the fees specified for the items that apply to the services, other than the item with the highest fee, are reduced by 50%.

  2. (2)

    For the purposes of subclause (1):

    1. (a)

      if 2 or more applicable fees are equally the highest, only one of those fees is taken to be the highest fee; and

    2. (b)

      if a reduced fee calculated under subclause (1) is not a multiple of 5 cents, the reduced fee is taken to be the nearest amount that is a multiple of 5 cents.

  1. 8

    Clause 2.5.9 of Schedule 1 (after table item 15)

Insert:

15A

63541

12 months

1

  1. 9

    At the end of Subdivision A of Division 2.5 of Part 2 of Schedule 1

Add:

2.5.9ACircumstances for suspecting prostate cancer for item 63541

  1. (1)

    For the purposes of subparagraph (a)(ii) of item 63541, the circumstances for suspecting a patient of developing prostate cancer are that:

    1. (a)

      2 PSA quantitation tests have been performed for the patient, with an interval between the tests of at least 1 month but not more than 3 months; and

    2. (b)

      subsection (2), (3), (4), (5) or (6) applies to the patient.

Patients at least 70 years of age

  1. (2)

    This subsection applies to a patient if:

    1. (a)

      the patient is at least 70 years of age; and

    2. (b)

      both PSA quantitation tests showed a PSA concentration of greater than 5.5 µg/L; and

    3. (c)

      a free/total PSA ratio test performed for the patient at least 1 month but not more than 3 months after the first PSA quantitation test showed a free/total PSA ratio of less than 25%.

Patients under 70 years of age without increased risk due to family history

  1. (3)

    This subsection applies to a patient if:

    1. (a)

      the patient is under 70 years of age; and

    2. (b)

      both PSA quantitation tests showed a PSA concentration of greater than 3 µg/L; and

    3. (c)

      a free/total PSA ratio test performed for the patient at least 1 month but not more than 3 months after the first PSA quantitation test showed a free/total PSA ratio of less than 25%.

  2. (4)

    This subsection applies to a patient if:

    1. (a)

      the patient is under 70 years of age; and

    2. (b)

      the first PSA quantitation test showed a PSA concentration of greater than 3 µg/L; and

    3. (c)

      the second PSA quantitation test showed a PSA concentration of greater than 5.5 µg/L.

Patients under 70 years of age with increased risk due to family history

  1. (5)

    This subsection applies to a patient if:

    1. (a)

      the patient is under 70 years of age; and

    2. (b)

      both PSA quantitation tests showed a PSA concentration of greater than 2 µg/L; and

    3. (c)

      a free/total PSA ratio test performed for the patient at least 1 month but not more than 3 months after the first PSA quantitation test showed a free/total PSA ratio of less than 25%; and

    4. (d)

      the patient has a first‑degree biological relative:

      1. (i)

        who has, or has had, prostate cancer; or

      2. (ii)

        who is suspected of carrying a BRCA 1 or BRCA 2 mutation.

  2. (6)

    This subsection applies to a patient if:

    1. (a)

      the patient is under 70 years of age; and

    2. (b)

      the first PSA quantitation test showed a PSA concentration of greater than 2 µg/L; and

    3. (c)

      the second PSA quantitation test showed a PSA concentration of greater than 5.5 µg/L; and

    4. (d)

      the patient has a first‑degree biological relative:

      1. (i)

        who has, or has had, prostate cancer; or

      2. (ii)

        who is suspected of carrying a BRCA 1 or BRCA 2 mutation.

2.5.9BRestriction on item 63453—timing and purpose

  1. (1)

    Subject to subclauses (2) and (3), item 63543 is applicable to a service described in that item for a patient with a diagnosis of prostate cancer if it is:

    1. (a)

      the first service provided after the date of the diagnosis; or

    2. (b)

      the first service provided after 12 months after the date of the service mentioned in paragraph (a); or

    3. (c)

      the first service provided after 3 years after the date of a service to which item 63543 applied under paragraph (b) or this paragraph.

  2. (2)

    Subject to subclause (3), item 63543 is also applicable to a service described in that item if the clinical need for the service is:

    1. (a)

      stated in the request for the service; and

    2. (b)

      appropriately documented in the record of the service.

  3. (3)

    Item 63543 is not applicable to a service provided for the purposes of:

    1. (a)

      treatment planning; or

    2. (b)

      monitoring after treatment of prostate cancer.

10

Schedule 1 (item 63489)

Repeal the item, substitute:

63489

MRI—scan of one breast, performed in conjunction with a biopsy procedure on that breast and an ultrasound scan of that breast, if:

(a) the request for the MRI scan identifies that the patient has a suspicious lesion seen on MRI but not on conventional imaging; and

(b) the ultrasound scan is performed immediately before the MRI scan and confirms that the lesion is not amenable to biopsy guided by conventional imaging; and

(c) a dedicated breast coil is used (R) (Anaes.)

1,008.00

11

Schedule 1 (after item 63533)

Insert:

63541

Multiparametric MRI—scan of the prostate for the detection of cancer, requested by a specialist in the speciality of urology, radiation oncology or medical oncology:

(a) if the request for the scan identifies that the patient is suspected of developing prostate cancer:

(i) on the basis of a digital rectal examination; or

(ii) in the circumstances mentioned in clause 2.5.9A; and

(b) using a standardised image acquisition protocol involving:

(i) T2‑weighted imaging; and

(ii) diffusion‑weighted imaging; and

(iii) (unless contraindicated) dynamic contrast enhancement

(R) (Anaes)

450.00

63543

Multiparametric MRI—scan of the prostate for the assessment of cancer, requested by a specialist in the speciality of urology, radiation oncology or medical oncology:

(a) if the request for the scan identifies that the patient:

(i) is under active surveillance following a confirmed diagnosis of prostate cancer by biopsy histopathology; and

(ii) is not undergoing, or planning to undergo, treatment for prostate cancer; and

(b) using a standardised image acquisition protocol involving:

(i) T2‑weighted imaging; and

(ii) diffusion‑weighted imaging; and

(iii) (unless contraindicated) dynamic contrast enhancement

(R) (Anaes)

450.00

12

Clause 3.1 of Schedule 1

Insert:

PSA is short for prostate specific antigen.

Part 5Technical amendments

Health Insurance (Diagnostic Imaging Services Table) Regulations (No. 2) 2020

13

Clause 1.2.20 of Schedule 1

Repeal the clause.

14

Clause 1.2.21 of Schedule 1 (heading)

Repeal the heading, substitute:

1.2.21Reduction in fees—multiple services on same day—general

15

Subclauses 1.2.21(6) and (7) of Schedule 1

Omit “1.2.20”, substitute “2.1.2A”.

16

Before clause 2.1.3 of Schedule 1

Insert:

2.1.2AReduction in fees—multiple services on same day—vascular ultrasounds

  1. (1)

    If a medical practitioner provides 2 or more vascular ultrasound services for the same patient on the same day, the fees specified for the items that apply to the services are reduced as follows:

    1. (a)

      the second highest fee is reduced by 40%;

    2. (b)

      any other fee, except the highest, is reduced by 50%.

  2. (2)

    For the purposes of subclause (1):

    1. (a)

      if 2 or more applicable fees are equally the highest:

      1. (i)

        only one of those fees is taken to be the highest fee; and

      2. (ii)

        the other, or another, highest fee is taken to be the second highest fee; and

    2. (b)

      if 2 or more fees are equally second highest—any one of those fees may be taken to be the second highest for the purpose of paragraph (1)(b); and

    3. (c)

      if a reduced fee calculated under subclause (1) is not a multiple of 5 cents—the reduced fee is taken to be the nearest amount that is a multiple of 5 cents.

  3. (3)

    This clause does not apply to the fee specified in item 64990 or 64991.

17

Clause 2.1.17 of Schedule 1 (heading)

Repeal the heading, substitute:

2.1.17Reduction in fees—multiple services on same day—transthoracic and stress echocardiograms

Schedule 3Pathology servicesPart 1Group P2: chemical

Health Insurance (Pathology Services Table) Regulations 2020

1

Schedule 1 (after item 66519)

Insert:

66522

Faecal calprotectin test for the diagnosis of inflammatory bowel disease, if all the following apply:

(a) the patient is under 50 years of age;

(b) the patient has gastrointestinal symptoms suggestive of inflammatory or functional bowel disease of more than 6 weeks’ duration;

(c) infectious causes have been excluded;

(d) the likelihood of malignancy has been assessed as low;

(e) no relevant clinical alarms are present

75.00

66523

Faecal calprotectin test for the diagnosis of inflammatory bowel disease, if all the following apply:

(a) the results of a service to which item 66522 applies were inconclusive for the patient (that is, the results showed a faecal calprotectin level of more than 50 μg/g but not more than 100 μg/g);

(b) the patient has ongoing gastrointestinal symptoms suggestive of inflammatory or functional bowel disease;

(c) the service is requested by a specialist or consultant physician practising asa specialist gastroenterologist;

(d) the request indicates that an endoscopic examination is not initially required;

(e) no relevant clinical alarms are present

75.00

Part 2Group P4: immunology

Health Insurance (Pathology Services Table) Regulations 2020

2

Schedule 1 (after item 71170)

Insert:

71175

A test, requested by a specialist or consultant physician, to diagnose neuromyelitis optica spectrum disorder (NMOSD) or myelin oligodendrocyte glycoprotein antibody‑related demyelination (MARD), by the detection of one or more antibodies, for a patient:

(a) suspected of having NMOSD or MARD; and

(b) with any of the following:

(i) recurrent, bilateral or severe optic neuritis;

(ii) recurrent longitudinal extensive transverse myelitis (LETM);

(iii) area postrema syndrome (unexplained hiccups, nausea or vomiting);

(iv) acute brainstem syndrome;

(v) symptomatic narcolepsy or acute diencephalic clinical syndrome with typical NMOSD magnetic resonance imaging lesions;

(vi) symptomatic cerebral syndrome with typical NMOSD magnetic resonance imaging lesions;

(vii) monophasic neuromyelitis optica (no recurrence, and simultaneous or closely related optic neuritis and LETM within 30 days of each other);

(viii) acute disseminated encephalomyelitis;

(ix) aseptic meningitis and encephalomyelitis;

(x) poor recovery from multiple sclerosis relapses

Applicable not more than 4 times in 12 months

50.00

Part 3Group P7: genetics

Health Insurance (Pathology Services Table) Regulations 2020

3

Before clause 2.7.1 of Schedule 1

Insert:

2.7.1ARestriction on item 73287—conjunction with item 73388

Item 73287 applies to a service described in that item only if the service is not performed in conjunction with a service described in item 73388.

2.7.1BRestriction on item 73290—conjunction with item 73391

Item 73290 applies to a service described in that item only if the service is not performed in conjunction with a service described in item 73391.

4

After clause 2.7.3 of Schedule 1

Insert:

2.7.3AItems 73384 to 73387 (relating to pre‑implantation genetic testing)—patient eligibility

A patient is eligible for a service described in any of items 73384 to 73387 only if:

  1. (a)

    the patient or the patient’s reproductive partner:

    1. (i)

      has an identified gene variant which places the patient at risk of having a pregnancy affected by a Mendelian or mitochondrial disorder; or

    2. (ii)

      is at risk of an autosomal dominant disorder which places the patient at risk of having a child who develops the autosomal dominant disorder; or

    3. (iii)

      has a chromosome re‑arrangement or copy number variant which places the patient at risk of having a pregnancy affected by a chromosome disorder; and

  2. (b)

    there is no curative treatment for the disorder and there is severe limitation of quality of life despite contemporary management of the disorder; and

  3. (c)

    the patient has previously had a consultation, with a specialist or consultant physician practising as a clinical geneticist, that included a discussion about the disorder.

5

Schedule 1 (cell at item 73297, column 2)

Repeal the cell, substitute:

Characterisation of germline gene variants, including copy number variation:

(a) in one or more of the following genes:

(i) BRCA1;

(ii) BRCA2;

(iii) STK11;

(iv) PTEN;

(v) CDH1;

(vi) PALB2;

(vii) TP53; and

(b) in a patient who:

(i) is a biological relative of a patient who has had a pathogenic or likely pathogenic gene variant identified in one or more of the genes mentioned in paragraph (a); and

(ii) has not previously received a service to which item 73295, 73296 or 73302 applies;

requested by a specialist or consultant physician

6

Schedule 1 (cell at item 73361, column 2)

Repeal the cell, substitute:

Testing of a person (the person tested) for the detection of a single gene variant for diagnostic purposes, if:

(a) the person tested has a biological sibling (the sibling) with a known monogenic condition; and

(b) a service described in item 73358, 73359 or 73360 has identified the causative variant for the sibling’s condition; and

(c) the results of the testing performed for the sibling are made available for the purpose of providing the detection for the person tested; and

(d) the detection is:

(i) requested by a consultant physician practising as a clinical geneticist; or

(ii) requested by a consultant physician practising as a specialist paediatrician, following consultation with a clinical geneticist; and

(e) the detection is not performed in conjunction with a service to which item 73362 or 73363 applies

Applicable only once per variant per lifetime

7

Schedule 1 (cell at item 73362, column 2)

Repeal the cell, substitute:

Testing of a person (the person tested) for the detection of a single gene variant for the purpose of reproductive decision making, if:

(a) the person tested has a first‑degree relative (the relative) with a known monogenic condition; and

(b) a service described in item 73358, 73359 or 73360 has identified the causative variant for the relative’s condition; and

(c) the results of the testing performed for the relative are made available for the purpose of providing the detection for the person tested; and

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

(e) the detection is not performed in conjunction with item 73359, 73361 or 73363

Applicable only once per variant per lifetime

8

Schedule 1 (cell at item 73363, column 2)

Repeal the cell, substitute:

Testing of a person (the person tested) for the detection of a single gene variant for segregation analysis in relation to another person (the patient), if:

(a) the patient has a known phenotype of a suspected monogenic condition; and

(b) a service described in item 73358 or 73360 has identified a potentially causative variant for the patient; and

(c) the person tested is a biological parent or other biological relative of the patient; and

(d) a sample from the person tested has not previously been tested in relation to the patientfor a service to which item 73359 applies; and

(e) the results of the testing of theperson tested for this service are made available for the purpose of providing the detection for the patient; and

(f) the detection is:

(i) requested by a consultant physician practising as a clinical geneticist; or

(ii) requested by a consultant physician practising as a specialist paediatrician, following consultation with a clinical geneticist; and

(g) the detection is not performed in conjunction with item 73361 or 73362

Applicable only once per variant per lifetime

  1. 9

    At the end of Division 2.7 of Part 2 of Schedule 1

Add:

73384

Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A, of samples from the patient and (if relevant) the patient’s reproductive partner, for the purpose of providing an assay for pre‑implantation genetic testing, requested by a specialist or consultant physician

Applicable not more than once per patient episode per disorder (of a kind described in clause 2.7.3A) per reproductive relationship

1,736.00

73385

Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A, of embryonic tissue from a sample from one embryo, if the analysis is:

(a) for the purpose of providing a pre‑implantation genetic test; and

(b) requested by a specialist or consultant physician; and

(c) performed in the assisted reproductive treatment cycle in which the embryo was produced

Applicable not more than once per embryo

635.00

73386

Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A, of embryonic tissue from samples from 2 embryos, if the analysis is:

(a) for the purpose of providing a pre‑implantation genetic test; and

(b) requested by a specialist or consultant physician; and

(c) performed in the assisted reproductive treatment cycle in which the embryos were produced

Applicable not more than once per assisted reproductive treatment cycle, and not more than once for the 2 embryos tested

1,270.00

73387

Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A, of embryonic tissue from samples from 3 or more embryos, if the analysis is:

(a) for the purpose of providing a pre‑implantation genetic test; and

(b) requested by a specialist or consultant physician; and

(c) performed in the assisted reproductive treatment cycle in which the embryos were produced

Applicable not more than once per assisted reproductive treatment cycle for the 3 or more embryos tested

1,905.00

73388

Analysis of chromosomes by genome‑wide microarray, of a sample from amniocentesis or chorionic villus sampling, including targeted assessment of specific regions for constitutional genetic abnormalities in diagnostic studies of a fetus, if

(a) one or more major fetal structural abnormalities have been detected on ultrasound; or

(b) nuchal translucency was greater than 3.5 mm

Applicable only once per fetus

589.90

73389

Analysis of products of conception from a patient with suspected hydatidiform mole for the characterisation of ploidy status

Applicable once per pregnancy

340.00

73391

Analysis of chromosomes by genome‑wide microarray in diagnostic studies of a patient with multiple myeloma

Applicable once per lifetime

589.90

10

Clause 4.1 of Schedule 1

Insert:

treatment cycle has the same meaning as in the general medical services table.

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