Health Insurance (Positron Emission Tomography) Determination HS/07/05 (Cth)
Health Insurance (Positron Emission Tomography) Determination HS/07/05
I, TONY ABBOTT, Minister for Health and Ageing, make this determination under section 3C of the Health Insurance Act 1973.
Dated 6/12/ 2005
Tony Abbott
Minister for Health and Ageing
Contents
1.Name of Determination1 3
2.Commencement and term 3
3.Interpretation 3
4.Circumstances where this Determination applies 4
5.Treatment of certain positron emission tomography services 5
6.Certain positron emission tomography services—items and specifications etc 6
Schedule – Specified health services 7
Name of Determination1
This Determination is the Health Insurance (Positron Emission Tomography) Determination HS/07/05.
Commencement and term
This Determination commences on the day after it is registered and shall remain in force until midnight on 31 October 2007.
Interpretation
In this Determination:
Act means the Health Insurance Act 1973.
ANZAPNM means the Australian and New Zealand Association of Physicians in Nuclear Medicine Inc, a body incorporated under the Associations Incorporation Act 1987 (WA).
authorised officer means, in relation to functions under this Determination:
(a)an employee of Medicare Australia authorised by the CEO of Medicare Australia; and
(b)an APS employee (within the meaning of the Public Service Act 1999) authorised by the Secretary.
facility means an accredited and comprehensive facility referred to in subsection 4(3).
FDG means 18F-fluorodeoxyglucose.
PET means positron emission tomography.
quarter means a period of three months beginning on 1 January, 1 April, 1 July or 1 October of any year.
RACP means the Royal Australasian College of Physicians (ACN 000 039 047).
RANZCR means the Royal Australian and New Zealand College of Radiologists (ACN 000 029 863).
relevant service means a health service, as defined in subsection 3C(8) of the Act, that is specified in the Schedule.
throughput requirement has the meaning given by subsection 4(6).
Note Unless the contrary intention appears, expressions used in this determination have the same meanings as in the Act—see section 13 of the Legislative Instruments Act 2003.
Unless the contrary intention appears, in this Determination a reference to a provision of the Act or regulations made under the Act 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.
Circumstances where this Determination applies
This Determination applies only in the following circumstances:
(a)where the relevant service is rendered:
(i)pursuant to a written request made by a specialist or a consultant physician who determined that the service was necessary and whose patient the person was; and
Note This circumstance mirrors the requirement in paragraph 16B(1)(b) of the Act that, for a medicare benefit to be payable in respect of an R-type diagnostic imaging service, the service must be rendered pursuant to a written request, but limits which practitioners may request a relevant service
(ii)by or under the personal supervision of a credentialled specialist referred to in subsection (2); and
(iii)at an accredited and comprehensive facility as referred to in subsection (3); and
(iv)using equipment that meets each of the standards specified by ANZAPNM as referred to in subsection (5); and
(b)the owner or operator of the equipment used to provide the relevant services has not been given written notice by an authorised officer that the equipment fails to meet the throughput requirement referred to in subsection (6) and that notice remains in effect; and
(c)where the owner or operator of the equipment used to provide the relevant service has provided a statutory declaration as referred to in subsection (7); and
(d)if the circumstances declared in the statutory declaration referred to in paragraph (c) have changed, the owner or operator has given Medicare Australia written notice of the change as soon as the changed circumstances have come to the attention of the owner or operator, as the case may be.
A credentialled specialist is a specialist or a consultant physician (not being the requesting practitioner mentioned in subparagraph (1)(a)(i)) credentialled under the 'Joint Nuclear Medicine Specialist Credentialling Program for the Recognition of the Credentials of Nuclear Medicine Specialists for Positron Emission Tomography' overseen by the Joint Nuclear Medicine Credentialling and Accreditation Committee established from time to time by the RACP and the RANZCR.
An accredited and comprehensive facility is a facility that:
(a)is accredited by ANZAPNM as a site for advanced training in PET; and
(b)provides from one location each of the following services (whether or not other services are also provided):
(i)PET;
(ii)computed tomography;
(iii)x-ray;
(iv)diagnostic ultrasound;
(v)medical oncology;
(vi)surgical oncology;
(vii)radiation oncology; and
(viii)neurology, including neurosurgery.
For paragraph (3)(b), the reference to one location means:
(a)all or part of one building; or
(b)if the services mentioned in paragraph (3)(b) are not rendered in the same building, only those facilities where public access between the buildings where the services are rendered is by way of a covered pedestrian walkway.
For subparagraph (1)(a)(iv), the standards specified by ANZAPNM are the:
(a)Interim Recommendations for PET Accreditation (Technical Aspects) dated 16 May 2001 and issued by the Australian and New Zealand Society of Nuclear Medicine (a body incorporated under the Associations Incorporation Act 1984 (NSW)), but not including the NEMA NU 2-2000 standard referred to in that document; and
(b)NEMA NU 2-2001 standard published on 20 June 2001 and issued by the National Electrical Manufacturers Assocation, a non-stock corporation organized under the General Corporation Law of the State of Deleware (United States of America).
being those documents in existence immediately before this Determination commences.
For paragraph (1)(b), the throughput requirement is that each piece of PET equipment located in the facility is used to render at least 20 relevant services each quarter following the quarter when the equipment is first used to render a relevant service.
For paragraph (1)(b), an authorised officer may, by written notice to the owner or operator of the equipment, revoke a notice referred to in that paragraph (1)(b) if satisfied that the equipment will meet the throughput requirement in future, having regard to action taken by the owner or operator (after the notice was given) aimed at meeting that requirement.
For paragraph (1)(c), if Medicare Australia gives written notice to the owner or operator of the equipment that it requires a statutory declaration to be provided in relation to the circumstances in this section, the owner or operator must provide the statutory declaration to Medicare Australia in the timeframe specified in the notice.
Treatment of certain positron emission tomography services
A relevant service shall be treated as if:
(a)it were both a professional service and a medical service for the purposes of the provisions of the Act and of regulations made under the Act, that make provision in respect of professional services or medical services; and
(b)it were both a professional service and a medical service for the purposes of the provisions of the National Health Act 1953, and of regulations made under that Act, that make provision in respect of professional services or medical services; and
(c)there were an item of an R-type diagnostic imaging service in the diagnostic imaging services table that:
(i)related to the relevant service; and
(ii)specified in respect of the service a fee in relation to a State, being the fee specified in the Schedule in relation to the State specified.
Certain positron emission tomography services—items and specifications etc
Each of the following provisions:
(a)subrule 3(1) of Part 2 of Schedule 1 of the Health Insurance (Diagnostic Imaging Services Table) Regulations 2004 or the regulations that replace them;
(b)any regulation made under the Act that identifies an item in the diagnostic imaging services table as an R-type diagnostic imaging service;
(c)regulation 13 of the Health Insurance Regulations 1975, so far it relates to professional services generally or diagnostic imaging services specifically,
shall have effect as if a relevant service, and the items that, by virtue of section 5(c), relate to a relevant service, were also specified in the provision.
Schedule – Specified health services
| Item | Health Service | Fee for all States |
| 61523 | Whole body FDG PET study, performed for evaluation of a solitary pulmonary nodule, where the lesion is considered unsuitable for transthoracic fine needle aspiration biopsy, or for which an attempt at pathological characterisation has failed. (R) | $953.00 |
| 61529 | Whole body FDG PET study, performed for the staging of proven non-small cell lung cancer, where curative surgery or radiotherapy is planned. (R) | $953.00 |
| 61559 | FDG PET study of the brain, performed for the evaluation of refractory epilepsy, which is being evaluated for surgery. (R) | $918.00 |
Note Section 3C(7) of the Act deems an internal territory to form part of the State of New South Wales.
Notes
1. All legislative instruments and compilations are registered on the Federal Register of Legislative Instruments kept under the Legislative Instruments Act 2003. See
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