Private Health Insurance (Prostheses) Rules 2007 (No. 4) (Cth)
Private Health Insurance (Prostheses) Rules 2007 (No.4)
I, VERONICA HANCOCK, delegate of the Minister for Health and Ageing, make these Rules under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.
Dated 27 November 2007
V Hancock
____________________________________
Veronica Hancock
Assistant Secretary
Private Health Insurance Branch,
Acute Care Division
Department of Health and Ageing
Contents
Part 1 Preliminary 3
1.Name of Rules 3
2.Commencement 3
3.Revocation 3
4.Definitions 3
Part 2 Benefit requirements 4
5.Listing of, and benefits, for prostheses 4
6.Benefits for prostheses provided as part of hospital treatment 4
7.Benefits for prostheses provided as part of hospital-substitute treatment 5
8.Timing of applications to have a prosthesis listed 5
9.Minister may have regard to recommendations and advice 6
Part 1 Preliminary
Name of Rules
These Rules are the Private Health Insurance (Prostheses) Rules 2007(No.4).
Commencement
These Rules commence on 15 December 2007.
Revocation
These Rules revoke the Private Health Insurance (Prostheses) Rules (No.2) 2007 (as amended) and the Private Health Insurance (Prostheses) Rules (No.3) 2007.
Definitions
Note: Terms used in these Rules have the same meaning as in the Act―see section 13 of the Legislative Instruments Act 2003. These terms include:
complying health insurance policy
hospital-substitute treatment
hospital treatment
medicare benefit
In these rules:
accredited podiatrist has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.
Act means the Private Health Insurance Act 2007.
gap permitted prosthesis means a prosthesis listed in the Schedule where an amount is specified for that prosthesis in the column under the heading 'Minimum Benefit' and a different amount is specified in the column under the heading 'Maximum Benefit'.
no gap prosthesis means a prosthesis listed in the Schedule where an amount is specified for that prosthesis in the column under the heading 'Minimum Benefit' and no amount is specified in the column under the heading 'Maximum Benefit'.
private hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a private hospital.
Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.
professional service has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.
public hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a public hospital.
Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.
Schedule means the Schedule in these Rules.
Part 2 Benefit requirements
Listing of, and benefits, for prostheses
For item 4 of the table in subsection 72-1 (2) of the Act:
(a)the Schedule lists the prostheses (listed prostheses) the Minister has listed under subsection 72-10 (5) of the Act and section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007; and
Note: Section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the listing of a prosthesis that was a no gap prosthesis or a gap permitted prosthesis for the purposes of the National Health Act 1953 immediately before the commencement of the Act.
(b)rule 6 sets out the method for working out the minimum benefit and maximum benefit for hospital treatment, covered under a complying private health insurance policy, that is the provision of a listed prosthesis in circumstances where:
(i)a medicare benefit is payable in respect of the professional service associated with the provision of the prosthesis; or
(ii)the provision of the prosthesis is associated with podiatric treatment by an accredited podiatrist; and
(c)rule 7 sets out the method for working out the minimum benefit and maximum benefit for hospital-substitute treatment, covered under a complying private health insurance policy, that is the provision of a listed prosthesis in circumstances where a medicare benefit is payable in respect of the professional service associated with the provision of the prosthesis.
Benefits for prostheses provided as part of hospital treatment
(1) For a no gap prosthesis provided as part of an episode of hospital treatment by a private hospital in the circumstances mentioned in paragraph 5 (b), the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in the Schedule under the heading ‘Minimum Benefit’.
(2) For a gap permitted prosthesis provided as part of an episode of hospital treatment by a private hospital in the circumstances mentioned in paragraph 5 (b):
(a)the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and
(b)the maximum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Maximum Benefit’.
(3) For a no gap prosthesis provided as part of an episode of hospital treatment by a public hospital in the circumstances mentioned in paragraph 5 (b):
(a)the minimum benefit is the lesser of the following amounts:
(i)the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or
(ii)the amount of the insured person’s liability to the public hospital for that prosthesis; and
(b)the maximum benefit is the amount for that prosthesis listed in the column under the heading 'Minimum Benefit'.
(4) For a gap permitted prosthesis provided as part of an episode of hospital treatment by a public hospital in the circumstances mentioned in paragraph 5 (b):
(a)the minimum benefit is the lesser of the following amounts:
(i)the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or
(ii)the amount of the insured person’s liability to the public hospital for that prosthesis; and
(b)the maximum benefit is the amount for that prosthesis listed in the column under the heading ‘Maximum Benefit’ in the Schedule.
Benefits for prostheses provided as part of hospital-substitute treatment
(1) For a no gap prosthesis provided as part of an episode of hospital-substitute treatment in the circumstances mentioned in paragraph 5 (c) the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in the Schedule under the heading ‘Minimum Benefit’.
(2) For a gap permitted prosthesis provided as part of an episode of hospital-substitute treatment in the circumstances mentioned in paragraph 5 (c):
(a)the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and
(b)the maximum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Maximum Benefit’.
Note: Private health insurers cannot cover, as part of hospital-substitute treatment, a service for which medicare benefit is payable unless the service is specified in the Private Health Insurance (Health Insurance Business) Rules 2007―see paragraph 121-10 (3) (a) of the Act.
Timing of applications to have a prosthesis listed
As a matter of normal administrative practice, applications made under subsection 72-10 (2) of the Act will be considered after they have been received and, if the Minister decides to grant the application, the prosthesis will be listed in the Schedule the next time the Minister makes or varies the Rules.
Note 1: Under subsection 72-10 (5) of the Act the Minister must list the kind of prosthesis, set out the minimum benefit and, if the Minister considers it appropriate, the maximum benefit for the prosthesis in these Rules on the next occasion that the Minister makes or varies the Rules after he or she grants an application and the applicant has paid to the Commonwealth any initial listing fee within 14 days of being informed of the Minister's decision to grant the application.
Note 2: Under subsection 72-15 (3) of the Act, the Minister may remove a prosthesis from the list in the Rules if the applicant fails to pay an ongoing listing fee.
Minister may have regard to recommendations and advice
(1) In making the decision under subsection 72-10 of the Act, the Minister may have regard to a recommendation from the Prostheses and Devices Committee.
(2) In setting the minimum and the maximum (if any) amounts for a prosthesis, the Minister may have regard to the amounts as negotiated between the Prostheses and Devices Negotiating Group and the applicant.
Note
All legislative instruments and compilations are registered on the Federal Register of Legislative Instruments kept under the Legislative Instruments Act 2003. See A - Prostheses
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Catheters, Angioplasty, Laser
Pacing Importers Pty Ltd - Life Systems
PI001 Excimer Laser Stent Polyester Fibre optic catheter 2.5 and 2.2mm $6,800.00
PI002 Excimer Laser Stent Polyester Fibre optic fibre catheter 0.457mm, 0.9mm, 1.4mm, $6,800.00
1.7mm and 2.0mm
Coronary Stents
Drug Eluting Stents
Abbott Australasia Pty Ltd
AY023 Xience V Everolimus Eluting Coronary Everolimus Eluting Coronary Stent 2.50mm to 4.0mm diameter, $3,450.00
Stent System 8mm to 28mm length
Boston Scientific Australia Pty Ltd
BS074 Taxus on Express2 Coronary Stent balloon expandable stent with conformal Length 8 - 32mm; Diameter $3,450.00
System Models 38001-0822 to 0840; polymer/drug matrix coating, pre- 2.25 - 5.0mm
38001-1222 to 1250; 38001-1622 to mounted on high pressure monorail
1650;
38001-2022 to 2050; 38001-2422 to
2450; 38001-2827 to 2850; 38001-3227
BS099 Taxus Liberte Paclitaxel-Eluting 316L Stainless Steel Stent with Translute 2.0mm-5.0mm & 8.0mm-38mm $3,450.00
Coronary Stent System Polymer and Paclitaxel
BS125 Promus Everolimus Coronary Stent Cobalt chromium alloy stent coated with Diameter 2.5, 3.0, 3.5 4.0mm. $3,450.00
a blended polymer mixed with Everolimus. Lengths 8, 12, 15, 18, 23,
Prostheses List by Category, Groups and Sponsor Page 1 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Johnson & Johnson Medical Pty Ltd
JJ302 CYPHER Sirolimus-Eluting Stent & Stainless steel coronary stent with Diameter 2.25 - 5.0mm, length $3,450.00
Delivery System Model CRS - 23300, Rapamycin (an immunosuppressive and 8-33mm
08225, 08250, 08275, 08300, 28225, antiproliferative drug) bound to the stent
28250, 28275, 28300, 33225, 33250,
33275, 33300, 13225, 13250, 13275,
18225, 18250, 18275, 18300, 23225,
23250, 23275, 23350, 23400, 08350,
08400, 28350, 28400, 33350, 33400,
13300, 13350, 13400, 18350, 18400,
23450, 23500, 28450, 28500, 33450,
33500, 08450, 13450, 18450, 18500
JJ481 CYPHER SELECT Sirolimus-Eluting Stainless steel coronary stent with Diameter 2.25 - 5.0mm, length 8 $3,450.00
Stent & Delivery System Sirolimus (an immunosuppressive and - 33mm
anti-proliferative drug) bound to the stent
by a polymer. Model CRA-23300, 08225,
08250, 08275, 08300, 28225, 28250,
28275, 28300, 33225, 33250, 33275,
33300, 13225, 13250, 13275, 18225,
18250, 18275, 18300, 23225, 23250,
23275, 23350, 23400, 08350, 08400,
28350, 238400, 33350, 33400, 13300,
13350, 13400, 18350, 18400, 23450,
23500, 28450, 28500, 33450, 33500,
JJ587 CYPHER Select Plus Sirolimus Eluting Stainless steel coronary stent with Diameter 2.25 - 5.00mm, $3,450.00
Coronary Stent Sirolimus bound to the stent by a polymer Length 8 - 33mm
Medtronic Australasia Pty Ltd
MC732 Endeavour Drug Eluting Coronary Stent Cobalt Alloy, ABT - 578 Diameter: 2.25mm-4.5mm; $3,450.00
System Length: 8.00mm-38.0mm
General Purpose Bare Metal Stents
Abbott Australasia Pty Ltd
AY025 Stents ACS Multilink Coronary Stent; ACS 1.5mm - 8.0mm $1,248.00
Megalink Peripheral Stent; ACS RX
Herculink Peripheral Stent. Stainless steel
AY026 Multilink Coronary Stent System Stainless Steel Length 1.5mm - 8.0mm $1,248.00
AY027 Multilink Coronary Stent System - 316L Stainless steel stent Length 1.5 - 8.0mm $2,496.00
AY028 Multilink Coronary Stent System - Cobalt chrome stent Length 1.5 - 8.0mm $1,248.00
Prostheses List by Category, Groups and Sponsor Page 2 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Atrium Australia - Pacific Rim Pty Limited
AC022 Flyer RX Coronary Stent System Stainless Steel Coronary Stent Dia 2-5mm, Length 6-40mm $780.00
Biotronik Australia Pty Ltd
BT058 Lekton Motion Coated flexible stent, Balloon mounted Diameter 2.5mm to 4mm, $1,248.00
Length 8 - 30mm
BT065 Lekton Motion Mega Amorphous silicon carbide coated Diameter 4.5 and 5 mm; Length $1,248.00
13 - 40 mm
BT069 Lekton Motion Petite Amorphous silicon carbide coated Diameter 2, 2.25, 2.5mm; $1,248.00
Length 8-20mm
BT082 PRO-Kinetic Cobalth Chromium coronary stent system 8-40mm length 2-5mm diameter $1,200.00
Boston Scientific Australia Pty Ltd
BS069 Express 2/Liberte Coronary Stent Consists of a balloon expandable stent, Stent lengths: 8,12,16,20,24,28 $1,248.00
pre-mounted on a Maverick 2 Monorail & 32 mm Stent diameters: 2.25,
delivery catheter. 2.5, 2.75, 3.0, 3.5, 4.0, 4.5 &
Daralan Pty Ltd
DA001 S-Stent SRX1 316L Stainless Steel SRX1 - 2510 2.5 x 8.5mm; $600.00
SRX1 - 3010 3.0 x 8.5mm;
SRX1 - 3510L 3.5 x 8.5mm;
SRX1 - 4010L 4.0 x 8.5mm;
SRX1- 2512 2.5 x 11mm; SRX1
23012 3.0 x 11mm; SRX1 -
3512L 3.5 x 11mm; SRX1 -
4012L 4.0 x 11mm; SRX1 -
2515 2.5 x 14.4mm; SRX1 -
3015 3.0 x 14.4mm; SRX1 -
Johnson & Johnson Medical Pty Ltd
JJ026 BX Velocity with Hepacoat System Balloon expandable, stainless steel, $1,220.00
heparin coated
JJ200 BX Velocity Stent and Delivery System Stainless steel stent Diameter: 2.25-5.0 mm; Length $1,220.00
8 - 33 mm
JJ239 BX Sonic Stainless steel coronary stent mounted on Dia 2.25 - 4.0mm, lengths 8 - $1,220.00
a balloon delivery system
Prostheses List by Category, Groups and Sponsor Page 3 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Medtronic Australasia Pty Ltd
MC197 Medtronic AVE S660 Coronary Stents, Stainless Steel S660 Coronary Stent - Diameter $1,144.00
S670 Coronary Stents, S7 Coronary (2.5mm-2.75mm), Length
Stents, BeStent2, (9mm-24mm); S670 & S7
Coronary Stent - Diameter
(3mm-4mm), Length (9mm-
30mm); BeStent2 - Diameter
(2.5mm-4mm), Length (9mm-
MC329 Medtronic Driver, Micro Driver Cobalt Alloy Driver Stent: diameter (2.25 - $1,248.00
Coronary Stent System 4.5mm), length (8-30mm);
Micro-Driver Stent: diameter
(2.25 - 2.75mm), length (8 -
Neich Medical Pty Ltd
NM003 R Stent Evolution 2 Coronary Delivery 316LVM Stainless Steel Balloon Lengths - 9-33mm; Diameters - $1,144.00
System Expandable Stent (Tubular) 2.5-4.0mm
Pacing Importers Pty Ltd - Life Systems
PI003 Med-X-Flexy Stent Tubular Stent, Stainless steel 316L, Gold Dia 5 - 9mm length: 20 - $780.00
markers
Terumo Corporation Australia
TU001 Tsunami Gold Coronary Stent Stainless Steel mounted on balloon Diameter 2.0mm - 4.0mm, $1,248.00
Length 10mm - 30mm length
Special Purpose Stents
Abbott Australasia Pty Ltd
AY012 JoStent Coronary Stent Graft Stainless Steel/PTFE 9 - 26 mm x 2.5 - 5 mm $3,222.00
CRT Pacemakers
Generation 1
Guidant Australia Pty Ltd
GU143 Contak Renewal TR CRT -P Model Implantable cardiac pacemaker 45x54x8.5mm, 14cc, 26gm $9,360.00
H120, Model H125
Medtronic Australasia Pty Ltd
MC006 InSync model 8040 Stimulator Titanium 14.4cc $9,360.00
Prostheses List by Category, Groups and Sponsor Page 4 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Generation 2
Biotronik Australia Pty Ltd
BT056 Stratos LV Multiprogrammable, Biventricular, DDDRV One size only $12,480.00
BT085 Stratos LV-T Multiprogrammable Biventricular DDDRV One size only $12,480.00
with Home Monitoring
Guidant Australia Pty Ltd
GU142 Contak Renewal TR2 CRT - P Model Implantable Cardiac pacemaker 45x54x8.5mm, 14cc, 26gm $12,480.00
H140, Model H145
Medtronic Australasia Pty Ltd
MC226 Medtronic Insync III Triple Chamber Titanium One size only $12,480.00
Pacemaker Model 8042
St. Jude Medical Australia Pty Ltd
SJ072 Frontier II - Model 5596 Biventricular Cardiac Resynchronisation 49mm(h) x 52(1) x 6(t), 25g $12,480.00
Device with AF suppression algorithm -
Titanum
Dual Chamber ICDs
Generation 2
Progressive Medical
PG004 Alto II DR Dual Chamber Implantable One size only $38,480.00
Cardioverter Defibrillator
Generation 3
Biotronik Australia Pty Ltd
BT053 Lexos DR Dual chamber ICD, rate responsive One size only. $43,680.00
BT076 Lumos DR-T Dual Chamber ICD with home monitoring one size only $43,680.00
BT091 Lumax 300 DR-T ICD-DR with bidirectional Home One size only $43,680.00
Guidant Australia Pty Ltd
GU111 Ventak Prizm II DR Model 1861, titanium, dual chamber, One size only $43,680.00
adaptive rate
Prostheses List by Category, Groups and Sponsor Page 5 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
GU132 Vitality DR Model 1871 This device acts to defibrillate the heart Model 1871 Vitality DR Dual $43,680.00
chambers when the patient enters into an Chamber Rate Responsive
arrhythmia or uses shocks or anti tachy Pacemaker/Defibrillator
pacing to revert Ventricular Tachycardia
(VT) or Ventricular Fibrillation (VF).
While also acting as a dual chamber
GU149 Vitality 2 DR - Model T165 Implantable Cardiac Defibrillator 30cc ; 82g $43,680.00
GU150 Vitality 2 EL DR - Model T167 Implantable cardiac Defibrillator 35cc ; 90g $43,680.00
Medtronic Australasia Pty Ltd
MC363 EnTrust Model D153DRG, Dual chamber, VT 33cc, 63g $43,680.00
Therapies, 30J 33cc, 63g
Progressive Medical
PG009 OVATIO DR 6550 Titanium dual chamber ICD, 29 cc 29cc $43,680.00
St. Jude Medical Australia Pty Ltd
SJ049 Epic Plus DR Model V-236 Implantable Dual Chamber sensing, bradycardia 33cc $43,680.00
Cardioverter Defibrillator pacing with atrial fibrillation suppression
SJ070 Epic + DR Model V-233 ICD Dual Chamber Implantable Cardio-verter 33cc 70g $43,680.00
Defibrillator
SJ071 Epic + DR Model V-239 ICD Dual chamber implantable cardio-verter 33cc 70g $43,680.00
defibrillator
SJ092 Epic II + DR V-258 Epic II + DR V-258 Implantable 35cc, 72g $43,680.00
Cardioverter Defibrillator
SJ101 Epic II DR V-255 Epic II DR V-255 Implantable 34cc, 72g $43,680.00
Cardioverter Defibrillator
Dual Chamber ICDs with CRT
Generation 1
Biotronik Australia Pty Ltd
BT081 Kronos LV-T CRT ICD with home monitoring one size $40,560.00
Generation 2
Biotronik Australia Pty Ltd
BT088 Lumax 300 HF-T CRT-D with bidirectional Home One size only $45,760.00
Prostheses List by Category, Groups and Sponsor Page 6 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Boston Scientific Australia Pty Ltd
BS112 Contak Renewal 4 RF CRT-D CRT-D with RF telemetry, IS-1 39cc, 82g $47,840.00
connector H230
BS113 Contak Renewal 4 RF CRT-D CRT-D with RF telemetry, IS-1 39cc, 82g $47,840.00
connector H235
Guidant Australia Pty Ltd
GU134 Contak Renewal 2 This device acts to defibrillate the heart One Size Only $45,760.00
chambers when the patient enters into an
arrhythmia or uses shocks or anti tachy
pacing to revert Ventricular Tachycardia
(VT) or Ventricular Fibrillation (VF).
While also acting as a biventricular
GU147 Contak Renewal 4 CRT-D Model H190, Implantable dual-chamber defibrillator One size only $45,760.00
Model H195
Progressive Medical
PG007 OVATIO CRT-D 6750 Titanium, dual chamber ICD with CRT 30cc $45,760.00
St. Jude Medical Australia Pty Ltd
SJ062 Epic HF Model V-339 Implantable Cardioverter/defibrillator with dual One size only $45,760.00
Cardiac Defibrillator chamber (atrial and RV) sensing and
bradycardia pacing with ventricular
SJ067 Epic + HF Model V-350 ICD Epic + HF V-350 ICD is a cardioverter 36cc / 73g $45,760.00
defibrillator with dual chamber (atrial and
RV) sensing and bradycardia pacing with
ventricular resynchronisation therapy.
SJ098 Epic II+ HF V-357 Epic II + HF V-357 Cardiac 36cc, 74g $45,760.00
Resynchronisation Therapy Defibrillator
with V-V Timing programmability
SJ100 Epic II HF V-355 Epic II HF V-355 Cardiac 36cc,73g $45,760.00
resynchronisation Therapy Defibrillator
with V-V Timing programmability
Dual Chamber Pacemakers
Generation 1
Boston Scientific Australia Pty Ltd
BS123 Insignia AVT 882 VDD Pacemaker 10.0cc, 23.5g $5,200.00
Prostheses List by Category, Groups and Sponsor Page 7 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Guidant Australia Pty Ltd
GU079 Pulsar Model VDD 870 Titanium 3.2mm/IS-1 $5,200.00
Medtronic Australasia Pty Ltd
MC727 Adapta Pacemaker DDD Pacemaker 12.1cc $5,200.00 $6,500.00
Models ADD01 27.1g
St. Jude Medical Australia Pty Ltd
SJ050 Verity ADx Model XL DC 5256 Dual - Dual Chamber multi-programmable rate- 11cc, 23.5g $5,200.00
Chamber pacemaker adaptive pacing devices with extended
longevity
SJ061 Identity Adx Model XL DC 5286 Dual Identity ADx Model XL DC Model 5286 11cc, 23.5g $5,200.00
Chamber Pacemaker is an implantable, multi-programmable
rate-adaptive pacing device with AF
Generation 2
Medtronic Australasia Pty Ltd
MC713 Adapta Pacemaker VDDR Pacemaker 11.1cc $6,760.00
Models ADVDD01 23.6g
St. Jude Medical Australia Pty Ltd
SJ054 Identity ADx Model VDR 5480 Single Chamber multi-programmable rate- 8cc, 18g $6,760.00
implantable pacemaker adaptive pacing device with extended
longevity
SJ057 Verity ADx Model XL VDR 5456 Single Chamber multi-programmable rate- 11cc, 23.5g $6,760.00
implantable pacemaker adaptive pacing device with extended
longevity
Generation 3
Biotronik Australia Pty Ltd
BT029 Philos DR-A Model 122600 Implantable Multiprogrammable, rate responsive, 5mm ports, One size only $9,360.00
Pacemaker
BT047 Protos DR/CLS Dual chamber, rate responsive, closed One size only. $9,360.00
loop system.
BT060 Philos II DR Multiprogrammable, rate responsive, One size only $9,360.00
BT071 Philos II DR-T Dual Chamber Rate Responsive with One size only $9,360.00
Home Monitoring
Prostheses List by Category, Groups and Sponsor Page 8 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
BT079 Cylos DR-T Dual chamber dual sensor rate responsive one size $9,360.00
with home monitoring system option
Boston Scientific Australia Pty Ltd
BS126 Insignia AVT 1292 Dual chamber pacemaker 10.8cc, 25.4g $9,360.00
Guidant Australia Pty Ltd
GU120 Insignia Plus DR Model 1297, Insignia Dual Chamber Rate Responsive One size only $9,360.00
Plus DR Model 1298 Permanent Pacemaker
GU121 Insignia Entra DR Models Dual Chamber Rate Responsive One size only $9,360.00
Permanent Pacemaker
GU140 Insignia Ultra DR Model 1291 Implantable Cardiac Pacemaker One size only $9,360.00
GU141 Insignia Ultra DR Model 1290 Implantable Cardiac Pacemaker One size only $9,360.00
Progressive Medical
PG002 Talent II DR Pacemaker Model 233 Dula Chamber Pacemaker. 99% titanium 57.5 x 37.2 x 8mm $9,360.00
PG005 Symphony DR 2550 Active Implantable pacemaker 1 size only $9,360.00
St. Jude Medical Australia Pty Ltd
SJ051 Verity Adx Implantable Pacemaker, Dual - Chamber, multi-programmable, 45x52x6mm,11cc, 23g, 5mm or $9,360.00
Models XL DR 5356 and XL DR rate-responsive pacemaker withAF 6mm M/S
SJ056 Integrity ADx Model DR 5360 and XL Dual-Chamber, multi-programmable, rate- Model DR 5360 - 8cc, 18g, $9,360.00
DR 5366 responsive pacemaker with AF Model XL DR 5366 - 11cc, 23.5g
SJ059 Identity ADx Models DR 5380 and XL Dual-Chamber, multi-programmable, rate- ADx DR 5380: 43x44x6mm, $9,360.00
DR 5386 adaptive pacing devices with AF 18g and 8cc
ADx XL DR 5386: 44x52x6mm,
23.5g and 11cc
SJ089 Victory XL DR 5816 and DR 5810 Dual Chamber Rate Responsive 44x52x6mm; 23.5g; 11cc $9,360.00
Generation 4
Medtronic Australasia Pty Ltd
MC726 Adapta Pacemaker DR Pacemaker 11.1-14.2cc $11,440.00
Models ADDR01, ADDRS1, ADDRL1, 23.6g-31.3g
ADDR06, ADDR03
St. Jude Medical Australia Pty Ltd
SJ103 Zephyr XL DR 5826 and DR 5820 Dual Chamber Rate-Responsive 5826 - 23.5g, 11cc and 5820 - $11,440.00
18g, 8.5cc
Prostheses List by Category, Groups and Sponsor Page 9 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Fixation Device, Internal, Plate
Biomet Australia Pty Ltd
BI930 Sternalock Plates - xyphoid, "L" & square 4 hole $195.00
BI931 Sternalock Plates - "X" & "T" 5-8 hole $300.00
Fixation Device, Internal, Screw
Biomet Australia Pty Ltd
BI929 Sternalock Screws Ti 2.4-2.7mm x 8-12mm $44.00
Group 1- Cardiothoracic Mechanical Valves
Group 1a - Ball Valve, Standard
Edwards Lifesciences Pty Ltd
EL029 SE SIL Ball Valve Aortic Models Starr Edwards - Silastic Ball Valve. 16mm-34mm $3,930.00
1200/1260, SE SIL Ball Valve Mitral Composition: Stellite Alloy No. 21;
Model 6120 Polytetrafluroethelyne; polypropylene
cloth; Silicone rubber (contains 2% by
weight barium sulphate for radiopacity)
Group 1c - Bi-Leaflet, rotatable
Advanced Biomedical Pty Ltd
AB002 ATS medical open pivot heart valve Pyrolythic Carbon, Double Velour 16-33mm $6,000.00 $6,200.00
model 500FA standard flexi-cuff aortic Polyester, Titanium
valve series, ATS medical open pivot
heart valve model 500DM standard
flexi-cuff mitral valve series
AB064 ATS medical open pivot heart valve Pyrolythic Carbon, Double Velour 16-33mm $6,000.00 $6,200.00
model 501DA advanced performance Polyester, Titanium
(AP) aortic valve series, ATS medical
open pivot heart valve model 501DM
advanced performance (AP) mitral valve
Prostheses List by Category, Groups and Sponsor Page 10 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Medtronic Australasia Pty Ltd
MC292 Advantage Heart Valve - Aortic Model A7760 - Pyrolytic carbon, PET Diameter 19-31 mm $6,000.00
A7760
MC324 Advantage Supra Aortic Heart Valve Mechanical Heart Valve Pyrolite Carbon Diameter (mm): 19 - 25 $6,000.00
leaflets Pyrolite carbon ring
MC681 Advantage Mitral Mechanical Heart Valve 23mm-33mm $6,000.00
Reid Healthcare
RH001 Aortic On-X Prosthetic Heart Valve 27-29mm, 19mm, 21mm, $5,500.00
Models ONXA-19; ONXA-21; ONXA- 23mm, 25mm, 25-33mm, 27-
23; ONXA-25; ONXA-27/29; ONXM- 29mm, 31-33mm, 23mm,
23; ONXM-25; ONXM-27/29;
ONXM31/33; ONXMC25/33
St. Jude Medical Australia Pty Ltd
SJ037 St Jude Medical Aortic Expanded Cuff Aortic Expanded Cuff, Aortic Aortic Expanded 19 -31mm, $6,000.00
Heart Valve; St Jude Medical Aortic Hemodynamic Plus Cuff, Mitral Aortic Hemodynamic 17 -
Hemodynamic Plus Cuff Heart Valve; St Hemodynamic Cuff, Aortic & Mitral 27mm, Mitral Hemodynamic 17
Jude Medical Mitral Hemodynamic Plus -27mm, Rotatable 17 - 33mm
Cuff Heart Valve; St Jude Medical
Mechanical Heart Valve Masters Series
SJ039 Regent Prosthestic Heart Valves Standard Cuff - Model 17AGFN-751 - Standard cuff - 17-23mm, Flex $6,500.00
23AGFN-751, Flex Cuff - Mode cuff - 17-23mm
17AGFN-756 - 23AGFN-756
SJ116 Regent Prosthestic Heart Valves Standard Cuff - Model 25AGFN-751 - Standard cuff - 25-29mm, Flex $6,000.00
29AGFN-751, Flex Cuff - Mode cuff - 25-29mm
25AGFN-756 - 29AGFN-756
Tag Medical
TM003 Optiform Mechanical Valve 19mm to 33mm $5,500.00
Group 1e - Tilting Disc, rotatable
Medtronic Australasia Pty Ltd
MC013 Medtronic Hall Heart Valve Aortic Model A7700/M7700 Titanium. Pyrolite. A7700 - Diameter 20-31mm, $5,100.00 $5,625.00
A7700, Medtronic Hall Heart Valve Dacron, A7700EZ/M7700EZ Titanium. M7700 - Diameter 23-33mm,
Mitral Model M7700, Hall Easy Fit A7700EZ - Diameter 19-29mm,
Aortic Heart Valve Model A7700, Hall M7700EZ - Diameter 23-31mm
Easy Fit Mitral Heart Valve Model M7700
Prostheses List by Category, Groups and Sponsor Page 11 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 2 - Cardiothoracic Tissue Valves
Group 2a - Stented, porcine
Edwards Lifesciences Pty Ltd
EL030 CE Supra Annular Aortic Valve Model Carpentier-Edwards SAV Bioprosthesis. 19mm-33mm $4,445.00
2650 Carpentier-Edwards S.A.V Composition: Porcine Valve; Elgiloy
Bioprosthesis Model 6650 Mitral Valve Alloy; Silicone Rubber,
Medtronic Australasia Pty Ltd
MC701 Mosaic Cinch, Aortic, Mitral Models 305cxx, 310cxx 19mm - 35mm $4,445.00 $5,345.00
St. Jude Medical Australia Pty Ltd
SJ069 St Jude Medical Biocor Porcine St Jude Medical Biocor Porcine Aortic Valves - Tissue Annulus $4,445.00
Prosthetic Heart Valve Prosthetic Heart Valve is manufactured Diameter - 21-29mm, Implant
from selected procine aortic valve cusps Height - 11-15c; Mitral Valves -
that have been cross-linked with a Tissue Annulus Diameter - 25-
35mm, Implant Height - 8-
Group 2b - Stented, pericardial
Edwards Lifesciences Pty Ltd
EL031 Carpentier-Edwards Perimount Carpentier-Edwards Pericardial Models 2900/6900 19-33mm, $5,000.00
Pericardial Bioprosthesis - Models Bioprosthesis. Composition: Bovine Model 6900P 25, 27, 29, 31,
2900/6900 Carpentier-Edwards Pericardium; Elgiloy Alloy; Silicone
Perimount Plus Pericardial Bioprosthesis Rubber, Polytetrafluoroethylene
Mitral - Model 6900P
EL039 Edwards Perimount Magna Model 3000 Carpentier-Edwards Perimount Magna 19MM Aortic Pericardial Tissue $5,000.00 $5,690.00
composition: Glutaraldehyde treated Valve; 21MM Aortic Pericardial
bovine pericardium/elgiloy wireform Tissue Valve; 23MM Aortic
stent/polyester band/silicone rubber Pericardial Tissue Valve; 25MM
suture ring/polytetrafluoroethylene Aortic Pericardial Tissue Valve;
cloth/polyester cloth. 27MM Aortic Pericardial Tissue
Valve; 29MM Aortic Pericardial
Tissue Valve
Tag Medical
TM039 Mitroflow Pericardial Bioprosthesis 19-27mm $4,700.00
Prostheses List by Category, Groups and Sponsor Page 12 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 2c - Non-Stented, porcine
Edwards Lifesciences Pty Ltd
EL032 Baxter Edwards Prima Plus Stentless Edwards Prima Plus. Porcine Valve; 19mm-29mm for pack of 7 items $4,841.00
Bioprosthesis Model 2500P Prosthetic Woven Polyester Cloth.
Heart Valve
Medtronic Australasia Pty Ltd
MC015 Freestyle bioprosthesis Models 995xx, 995MSxx 19 - 35mm $5,110.00 $5,350.00
St. Jude Medical Australia Pty Ltd
SJ038 St Jude Medical Toronto SPV Valve Tissue Heart Valves, Bioimplant TSPV: 21 - 29mm, Bioimplant $4,900.00
Model SPA-101, St Jude Medical Aortic: 21-27mm, Bioimplant
Bioimplant Heart Valve Mitral: 27-32mm
Group 3 - Cardiothoracic Valve Conduits
Group 3a - Mechanical Valve
Advanced Biomedical Pty Ltd
AB001 ATS Medical open pivot aortic valved Pyrolythic Carbon, Double Velour 21- 33mm $6,950.00 $7,100.00
graft model 502AG Polyester, Titanium
Medtronic Australasia Pty Ltd
MC198 Medtronic Hall rotatable aortic valved Titanium, pyrolite, dacron 20 - 33mm $6,950.00
collagen impregnated conduit Model
St. Jude Medical Australia Pty Ltd
SJ036 St Jude Medical Coated Aortic Valved Coated Aortic Valved Graft 21mm - 33mm $6,950.00
SJ104 SJM Masters Series Aortic Valved St Jude Medical Mechanical Heart Valve Annulus Diameter 19-29mm $6,950.00
Prosthesis - VAVGJ sewn into the base of a woven polyester
fibre graft which has been impregnated
with bovine-derived gelatin
Tag Medical
TM002 CarboSeal Ascending Aortic Prosthesis, Mechanical Conduit AP 21-33mm, CP 21 - 33mm $6,950.00
sterile, CarboSeal Ascending Aortic
Prosthesis with Handle Model AP21,
Model AP23, Model AP25, Model AP27,
Model AP29, Model AP31, Model
AP33, Carboseal Valsalva
Prostheses List by Category, Groups and Sponsor Page 13 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 3b - Tissue Valve, stented porcine
Medtronic Australasia Pty Ltd
MC012 Medtronic Hancock Valved Conduit Porcine bioprosthesis, dacron 12, 14, 16, 18, 20, 22, 25, $5,900.00 $6,800.00
Model 100/150
Group 4 - Cardiothoracic Atrio-Ventricular Rings and Bands
Group 4a - Ring, Standard
Edwards Lifesciences Pty Ltd
EL028 Baxter Sterile Grafts, Implants & Carpentier-Edwards Classic Annuloplasty 24mm-40mm $2,200.00
Prostheses, Non-Animal Origin Ring. Composition: Titanium Alloy;
Annuloplasty: Ring-Mitral Ring with Silicone Rubber; Polyester Fabric
Holder; Mitral Cosgrove-Edwards Carpentier-Edwards Physio Annuloplasty
Annuloplasty System Model 4600; Ring. Composition: Elgiloy Bands;
Classic Annuloplasty Ring-Tricuspid Polyester Film Strips; Silicone Rubber;
Polyester Cloth, Cosgrove-Edwards
Annuloplasty Band. Composition: Silicone
Rubber; Polyester Cloth. Carpentier-
Edwards Tricuspid Ring. Composition:
Titanium Alloy; Silicone Rubber;
Medtronic Australasia Pty Ltd
MC005 Medtronic Duran Annuloplasty Ring; Annuloplasty Devices - Models 610R & Model 610R 25-35mm & Model $2,200.00
Duran Ancore Ring 620R; Duran 620R Silicone / Barium Sulphate, Dacron. 620R 23-35mm
Ancore Chordal Model 620RG
St. Jude Medical Australia Pty Ltd
SJ035 SJM Tailor Annuloplasty Ring Fully Flexible 25mm - 35mm $2,200.00
Tag Medical
TM001 AnnuloFlo Annuloplasty System Annuloflex Ring or AnnuloFlo Ring 26-36mm $2,000.00
Group 4b - Ring, with modification
Edwards Lifesciences Pty Ltd
EL049 Edwards Etlogix Annuloplasty Ring Titanium/silicon/dacron polyester 24mm/26mm/28mm/30mm/32m $2,400.00
cloth/plastic template Mitral valve annular m/34mmd
repair device designed specifically for
patients with Ischemic Mitral regurgitation
Prostheses List by Category, Groups and Sponsor Page 14 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Medtronic Australasia Pty Ltd
MC745 CG Future Composite Ring Semi-rigid mitral annuloplasty ring, with 24, 26, 28, 30, 32, 34, 36 & $2,400.00
anterior flexibility
St. Jude Medical Australia Pty Ltd
SJ087 St Jude Medical Rigid Saddle Ring Rigid Annuloplasty Ring 24 - 34mm $2,400.00
Group 4c - Band, Standard
Edwards Lifesciences Pty Ltd
EL050 Edwards MC3 Tricuspid Annuloplasty Annuloplasty Ring, 26mm to 36mm in 2mm $2,400.00
System titanium/silicone/polyester velour
cloth/plastic template
Group 4d - Band, with modification
Medtronic Australasia Pty Ltd
MC709 Posterior Annuloplasty Band; Colvin - Annuloplasty - Model 610B & 620B Model 610B: 25-35mm; Models $2,200.00
Galloway Future Band Model 638B; Silicone / Barium Sulphate, Dacron. 620B & 620BG: 23-35mm,
Duran Ancore Band 620B; Duran Models 638B semi-regid metal alloy core, Model 638B - 26-38mm
Ancore Chordal Model 620BG silicone coating, polyester knit fabric, kit
includes-band, malleable handle, template
with suture markers, sizers
St. Jude Medical Australia Pty Ltd
SJ088 SJM Tailor Annuloplasty Band Flexible double-velour, polyester fabric 25 - 35mm $2,200.00
Group 5 - Cardiothoracic Membranes and Patches
Group 5a - Tissue
Edwards Lifesciences Pty Ltd
EL033 Baxter Augmentation / Substitution Edwards Pericardial Patch. Bovine 10cm x 16cm $760.00
Material, Human or Animal Origin, Pericardium.
Sterile Pericardial Patch.
Group 5b - Synthetic, Cardiovascular
W L Gore & Associates
GT117 Gore-Tex - Cardiovascular Patch ePTFE 0.4mm Thickness 2 x 9cm $240.00
Prostheses List by Category, Groups and Sponsor Page 15 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
GT118 Gore-Tex - Cardiovascular Patch ePTFE 0.4mm - 3 x 6cm $280.00
0.6mm - 2.5cm x 15cm & 5cm
x 7.5cm
GT120 Gore-Tex Cardiovascular Patch ePTFE 0.6mm Thickness 5 x 15cm $521.00
GT121 Gore-Tex Cardiovascular Patch ePTFE 0.6mm Thickness 10 x 15cm $945.00
GT126 Acuseal Cardiovascular Patch Vascular ePTFE 0.5mm Thickness 1 x 9cm; 0.8 $223.00
x 7.5cm
GT127 Acuseal Cardiovascular Patch Cardiac ePTFE 0.5mm Thickness 3 x 6cm & 5 $270.00
x 7.5cm
Group 5c - Synthetic, Non-cardiovascular
W L Gore & Associates
GT122 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 6 x 12cm $360.00
GT123 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 8 x 16cm $643.00
GT124 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 12 x 12cm $748.00
GT125 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 15 x 20cm $1,455.00
Group 6 - Cardiothoracic Assisted Anastomic Devices
Medtronic Australasia Pty Ltd
MC680 Spyder Proximal Anastomotic Device 6-clip assembly $590.00
Group 7 - Cardiothoracic Assisted Fixation Devices
Medtronic Australasia Pty Ltd
MC714 U-Clips (Valve Repair) Double Arm, Mitral Valve Repair 2-packs $510.00
Prostheses List by Category, Groups and Sponsor Page 16 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 8 - Cardiothoracic Grafts (Proximal Aorta)
Group 8b Modified Tube
Terumo Corporation Australia
TU036 Gelweave Valsalva Graft Woven vascular prosthesis, polyester, Diameter 24 - 34 mm, Overall $3,320.00
gelatin sealed length 18.4 - 19.6cm
Group 8c Tube with one side branch
Terumo Corporation Australia
TU038 Gelweave Graft Straight Thoracic Graft, with antiflo side 20 -34 mm x 20-40 cm $1,715.00
branch, Polyester, woven, gelatin sealed
Group 8d Tube with multiple side branches (more than 1)
Terumo Corporation Australia
TU037 Gelweave Plexus Graft Multi Branched, for Aortic Arch 20 - 34 mm x 40 cm $2,150.00
reconstruction, Polyester, Woven, gelatin
sealed
ICD Leads
Group 1 - Coronary Sinus Leads
Medtronic Australasia Pty Ltd
MC026 Medtronic Transvene SVC Lead Model Model 6937-35, Model 6937-52, Model 35 - 110cm x 660mm $2,340.00
6937; 6937-58, Model 6937-110; Silicone;
Group 4 - Transvenous/Non steroid/Passive Leads
Progressive Medical
PG003 Swift 4040 1CT lead length 58 cm - 69 cm $7,280.00
Group 5 - Transvenous/Steroid/Passive Leads
Biotronik Australia Pty Ltd
BT077 Kentrox SL steriod Dual shock coil fractal steroid eluting 65, 75cm lengths $9,000.00
passive fixation electrode
Prostheses List by Category, Groups and Sponsor Page 17 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
BT078 Kentrox RV Steroid single shock coil fractal steroid eluting 65, 75 cm lenghts $9,000.00
passive fixation electrode
BT092 Linox TD Fractal and steroid coated passive fixation 65, 74 or 100cm length and 16 $9,360.00
quadripolar ICD lead or 18mm electrode spacing
BT093 Linox T Passive fix RV bipolar fractal coated 65, 75cm length $9,360.00
steroid ICD lead
Guidant Australia Pty Ltd
GU112 Endotak Reliance S Lead Model 0127 & Model 0128, defibrillation 59cm, 64cm $7,500.00
lead, 9fr introducer (silicone coated),
steroid eluting, high impedence
GU115 Endotak Reliance Lead Model 0147, Model 0148 & Model 0149, 59cm, 64cm, 90cm $7,500.00
defibrillation lead, 9fr introducer (silicone
coated), steroid eluting, high impedence
GU158 Endotak Reliance SG Passive Fixation Endotak Reliance SG Passive Fixation 54cm - 90cm $7,200.00
Lead: Models 0170, 0171, 0172, and
0173 Implantable cardioverter defibrillator
lead with GORE ™ ePTFE covered
GU159 Endotak Reliance G Passive Fixation Lead Endotak Reliance G Passive Fixation 54cm -90cm $7,200.00
Lead: Models 0174, 0175, 0176 and
0177. Implantable Cardioverter
defibrillator lead with GORE ™ ePTFE
Medtronic Australasia Pty Ltd
MC002 Medtronic Sprint Quattro Lead Model Silicone and polyurethane 65-100cm $9,360.00
6944RV/SVC 65cm; Model
6944RV/SVC 75cm; or Model
6944RV/SVC 100cm; Medtronic Sprint
Quattro Lead Model 6944RV/SVC 58cm
MC696 Sprint Fidelis Lead Model 6948, dual-coil, tined 58-100cm $9,360.00 $10,000.00
MC698 Sprint Fidelis Lead Model 6930, single-coil, tined 58-100cm $9,360.00 $10,000.00
St. Jude Medical Australia Pty Ltd
SJ016 Riata Transvenous Tachyarrhythmia Quadripolar, dual-coil, steroid eluting, One size only $9,360.00
Lead Model 1570, Model 1571 active fixation tachyarrhythmia leads
SJ083 Riata Transvenous Tachyarrhythmia Tri-polar Passive-Fixation, Steroid 60cm, 65cm, 8F introducer $9,360.00
Lead Model 1572 Eluting, Single Shock Coil
SJ085 Riata iTransvenous Tachyarrhythmia Passive Fixation, Steroid-Eluting, Dual 60cm, 65cm, 70cm, 8F $9,360.00
Leads Models 1560 and 1561 Shock Coil Defibrillation Lead
Prostheses List by Category, Groups and Sponsor Page 18 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
SJ086 Riata i Transvenous Tachyarrhythmia Passive Fixation, Steroid Eluting, Single 60cm, 65cm, 70cm, 8F $9,360.00
Lead Model 1562 Shock Coil Defibrillation Lead
SJ110 Riata ST Transvenous Tachyarrhythmia Riata ST 7040/41 Passive-Fixation True- 60 - 75cm, 6.3 Fr, 7 Fr $9,360.00
Leads 7040/41/42 and 7050/51/52 Bipolar, Dual-Coil, Steroid-eluting,
Endocardial Defibrillation Leads, 7042 -
Single Coil, 7050/51 - Integrated Bipolar,
Dual Coil, 7052 - Integrated Bipolar,
Single Coil
SJ113 Riata i TransvenousTachyarrhythmia Riata i 1950/51 - Passive-Fixation 60 - 75cm $9,360.00
Leads 1950/51 Integrated-Bipolar, Dual-Coil, Steroid-
Eluting, Endocardial Defibrillation Leads
Group 6 - Transvenous/ Steroid/Active Leads
Biotronik Australia Pty Ltd
BT064 Kentrox SL-S steroid Fractal coated steroid electrode, dual 16 and 18 cms tip to second $7,488.00
shock coil shock coil
BT068 Kentrox RV-S steroid Fractal coated steroid electrode, single 65cm lengths $7,488.00
shock coil
BT084 Linox SD Fractal coated and steroid electrode, 65, 75cm length, 16, 18mm elec $9,360.00
active fixation quadrapolar
BT096 Linox S Active fix RV bipolar fractal coated 65, 75cm length $9,360.00
steroid IC lead
Guidant Australia Pty Ltd
GU118 Endotak Endurance EZ Leads Model Defibrillation lead, steroid eluting, 64, 70, 100cm $7,500.00
0154, Model 0155, Model 0156 trilumen lead body contains one
conductor for pacing/sensing and two
conductors for defibrillation. The helix is
composed of platinum iridium.
GU145 Endotak Reliance G Lead Model 0164, Implantable defibrillator/pacemaker lead Lead Lengths: 59 - 90cm $9,000.00
Model 0165, Model 0166, Model 0167
GU146 Endotak Reliance SG Lead Model 0160, Implantable defibrillator/pacemaker lead Lead Lengths: 59 - 90cm $9,000.00
Model 0161, Model 0162, Model 0163
GU160 Endotak Reliance Active Fixation Lead Endotak Reliance Active Fixation Lead: 54cm - 90cm $7,200.00
Models 0157, 0158 and 0159 Implantable
cardioverter defibrillator lead
GU161 Endotak Reliance S Active Fixation Lead Endotak Reliance S Active Fixation Lead: 54cm - 90cm $7,200.00
Models 0137, 0138 and 0139
Prostheses List by Category, Groups and Sponsor Page 19 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
GU163 ENDOTAK RELIANCE G Lead 018 Endotak Reliance G Lead: Models 0184 to 59-90cm $7,200.00
0187. Implantable cardioverter
defribrillator lead. Active fixation.
GU164 ENDOTAK RELIANCE SG Lead 018 Endotak Reliance SG Lead: Models 0180 59-90cm $7,200.00
Series to 0183. Implantable cardioverter
defibrillator lead. Active fixation.
Medtronic Australasia Pty Ltd
MC208 Medtronic Sprint Quattro Secure Lead Leads, Defibrillator, Implantable, Silicone, 58-100cm $9,360.00
Model 6947 58cm; Model 6947 65cm; polyurethane, platinized tantalum coils,
Model 6947 75cm; Model 6947 100cm steroid eluting tip
MC695 Sprint Fidelis Lead Model 6949, dual-coil, screw-in 58-100cm $9,360.00 $10,000.00
MC697 Sprint Fidelis Lead Model 6931, single-coil, screw-in 58-100cm $9,360.00 $10,000.00
St. Jude Medical Australia Pty Ltd
SJ074 Riata Transvenous tachyarrhythmia Tri-polar Active - Fixation, Steroid- 60cm, 65cm, 8F introducer $9,360.00
Leads Model 1582 Eluting, Single shock Coil
SJ075 Riata Transvenous Tachyarrhythmia Quadripolar, dual-coil, steroid eluting, One size only $9,360.00
Lead Model 1580, Model 1581 active fixation tachyarrhythmia leads
SJ081 Riata i Transvenous Tachyarrhythmia Active fixation leads, Steroid Eluting, 60cm, 65cm, 75cm, 8F $9,360.00
Leads Model 1590/1591 Dual Shock Coil Defibrillation Lead
SJ084 Riata i Transvenous Tachyarrhythmia Active Fixation, Steroid Eluting, Single 60cm, 65cm, 75cm, 8F $9,360.00
Lead Model 1592 Shock Coil Defibrillation Lead
SJ096 Riata ST 7000/7001/7002 Active-Fixation True-Bipolar, Dual-Coil, 60, 65cm 7F introducer $9,360.00
(7002 - Single-Coil) Steroid-Eluting
Steroid Eluting, Endocardial Defibrillation
SJ102 Riata ST Transvenous Tachyarrhythmia Riata ST 7010/7011 Active-Fixation 60 - 75cm 6.3Fr, 7 Fr Introducer $9,360.00
Leads 7010/7011/7012 Integrated-Biopolar, Dual-Coil, Steroid-
eluting, Endocardial Defibrillation Leads,
7012 - Single Coil
SJ106 Riata Transvenous Tachyarrhythmia Riata 1940/41 Active-Fixation True- 60-75cm $9,360.00
Leads 1940/41/42 bipolar, Dual-Coil, Steroid-eluting,
Endocardial Defibrillation Leads, 1942 -
SJ108 Riata i Transvenous Tachyarrhythmia Riata i 1962 - Active Fixation Integrated- 60 - 75cm $9,360.00
Leads 1962 Bipolar, Single-Coil, Steroid-Eluting,
Endocardial Defibrillation Leads
Prostheses List by Category, Groups and Sponsor Page 20 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Limited Functionality ICDs
Generation 2
Biotronik Australia Pty Ltd
BT052 Cardiac Airbag Single chamber ICD rate responsive One size only. $15,600.00
Mesh, Polymeric
W L Gore & Associates
GT128 Helex Septal Occluder ePTFE 15-35mm $10,200.00
Occluders
Medtel Australia Pty Ltd
ME068 Amplatzer PFO Occluder Nitinol Wire Mesh 25mm & 35mm $10,200.00
St. Jude Medical Australia Pty Ltd
SJ091 Premere PFO Closure System Percutaneous, transcatheter, self- Left Atrial Anchor diameter $10,036.00
expanding, dual anchor, occlusion device 20mm and 25mm
Occluders, Vascular
Medtel Australia Pty Ltd
ME065 Amplatzer Duct Occluder Nitinol Wire Mesh 5 - 24mm $10,200.00
ME066 Amplatzer Septal Occluder Nitinol Wire Mesh 4mm - 40mm $10,200.00
ME067 Amplatzer Muscular VSD Occluder Nitinol Wire Mesh 4 - 24mm $10,200.00
ME074 Amplatzer Membranous VSD Occluder Nitinol wire mesh, double disc occluder 4-24mm, Length 7-10mm $10,200.00
and delivery system
Prostheses List by Category, Groups and Sponsor Page 21 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Pacemaker Lead Adapters, Implantable
Guidant Australia Pty Ltd
GU129 LV-1 Lead Adaptor to IS-1 Connects Left ventricular leads to IS-1 One size only $500.00
ports in pacemakers and defibrillators to
replace abnormal cardiac excitation
GU130 Y Adaptor Connects multiple defibrillator electrodes One size only $500.00
to a common port, enabling the use of
shocks to revert Ventricular Tachycardia
and normal cardiac function to return
Medtronic Australasia Pty Ltd
MC035 Medtronic lead Extender Kit Model: Silicone 14 - 50cm $530.00
6984M, 6981M, 6985M, 5866-24M,
5866-38M, 5866-40M, 6986M, 5866-
37M; Bipolar Lead Adaptor Kit Model
MC036 Medtronic Lead End Cap Kit Model: Silicone or Polyurethane; Plug to Seal IS- 10 - 25mm, IS-1 Pin Plug - One $80.00
5867-3M; Medtronic Adaptor Kit Line 1 connector in a pacemaker or Size only
5866-23; Connector Sleeve 5866-45; defibrillator, Silicone
Metronic lead sleeve kit model: 5866-46;
Medtronic Pinplug kit. Model 6719 (DF
- 1), 6725 (IS-1) Pin Plug
MC246 DF-I Y-Adaptor/Extender Model 6726 Silicone Lengths 25cm, 37cm $537.00
25cm & 37cm
Pacemaker leads
Group 1 - Non-transvenous, Bi-Polar, Steroid
Medtronic Australasia Pty Ltd
MC011 Capsure EPI steroid eluting bipolar Silicone 25 - 60cm $1,716.00
epicardial lead Model 4968 - ventricle
Group 11 - Transvenous, Bi-Polar, Passive, Steroid, Left Ventricular
Biotronik Australia Pty Ltd
BT095 Corox OTW BP Coronary Sinus bipolar steroid 77, 87 cm length $6,240.00
Prostheses List by Category, Groups and Sponsor Page 22 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Guidant Australia Pty Ltd
GU138 Easytrak 2, Model 4514,4515, 4516, The Easytrak 2 lead is a dual electrode $6,240.00
4517, 4518, 4519, 4520 version of the Easytrak lead. The
Easytrak 2 lead is a coronary sinus lead,
steroid eluting, dual electrode, pace/sense
lead. The lead provides chronic pacing
and sensing of the left ventricle by
placement in the coronary venous
GU153 Easytrak 2 Is-1 Lead - Models 4542, Implantable left ventricular pacemaker lead 80 to 100cm $6,240.00
4543 & 4544
GU156 Easytrak 3 Lead - Models 4521, 4522, Implantable left ventricular pacemaker lead 80 to 100cm $6,240.00
4523, 4524, 4525, 4526 and 4527
GU162 Easytrak 3 IS-1 Lead Models 4548, 4549 and 4550. Silicone Sizes 80 to 100cm $6,240.00
and polyurethane insulation and
polyurethane protective sleeve
GU165 Acuity Steerable Lead Steerable IS-1 bipolar CS LV Lead 80cm, 90 cm, 100cm $6,240.00
Models 4554, 4555, 4556
Medtronic Australasia Pty Ltd
MC699 Attain OTW Model 4194 Lead Model 4194 78cm, 88cm $6,240.00
St. Jude Medical Australia Pty Ltd
SJ099 QuickSite 1056T Bipolar Steroid-Eluting, Titanium Nitride 75cm, 6F and 86cm, 6F $6,240.00
Coated Electrodes Guidewire/Stylet-
Placed Keft Heart Lead with Fast-Pass
Group 2 - Non-transvenous, Uni-Polar, Steroid
Medtronic Australasia Pty Ltd
MC053 Capsure EPI steroid eluting unipolar Silicone 25 - 50cm $1,544.00
epicardial lead Model 4965 ventricle
Group 3 - Non-Transvenous, Uni-Polar, Non-Steroid
Guidant Australia Pty Ltd
GU037 Myocardial Pacing Lead Model 4312 and 4316 54cm and 35cm $1,144.00
Medtronic Australasia Pty Ltd
MC009 Medtronic Epicardial Pacing Leads IS-1 Silicone 35 - 53cm $1,144.00
Model 5071
Prostheses List by Category, Groups and Sponsor Page 23 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 4 - Transvenous, Uni-Polar, Passive, Steroid, Right Ventricular/Atrial
Medtronic Australasia Pty Ltd
MC254 CapSure Sense pacemaker lead Models Titanium Nitride 30 - 85cm $1,248.00 Also grouped in Pacemaker Lead
Group 8
St. Jude Medical Australia Pty Ltd
SJ078 IsoFlex S, Models 1645K, 1643K, Endocardial, Steroid Eluting, Silicone, 34cm, 40cm, 46cm, 52cm, $1,248.00
Passive Fixation Leads with Fast-Pass 58cm, 85cm, 7F
Group 5 - Transvenous, Uni-Polar, Passive, Non- Steroid, Left Ventricular
St. Jude Medical Australia Pty Ltd
SJ033 Aescula LV Model 1055K Left Ventricular Pacing Lead 75cm $2,735.00
Group 6 - Transvenous, Uni-Polar, Passive, Steroid, Left Ventricular
Biotronik Australia Pty Ltd
BT070 Corox OTW UP Steroid Coronary Sinus Lead 77, 87cm $3,000.00
Guidant Australia Pty Ltd
GU056 Easytrak Lead Model 4510, Model 4511, Model 4512 65cm, 72cm, 80cm $3,120.00
Transvenous Coronary Sinus Lead
GU152 Easytrak IS-1 Lead, Models 4535 to 4538 Implantable left ventricular pacemaker lead 80 - 90cm $3,120.00
Medtronic Australasia Pty Ltd
MC225 Attain Over the Wire Model 4193 Titanium, polyurethane 78-88cm $3,120.00
MC730 Attain StarFix LV Lead Over the wire left Ventrucular Lead 78, 88, 103cm $5,000.00 $6,240.00
St. Jude Medical Australia Pty Ltd
SJ079 QuickSite Model 1056K Unipolar, Steroid Eluting, Titanium Nitride 75cm, 6F and 86cm, 6F $3,120.00
Electrode, Guidewire/Stylet-placed Left
Heart Lead with Fast-Pass Coating
Group 8 - Transvenous, Bi-Polar, Passive, Steroid, Right Ventricular/Atrial
Biotronik Australia Pty Ltd
BT066 Selox ST Transvenous Bipolar Passive Steroid 53 and 60cm lengths $1,248.00
Ventricular Pacing Lead, fractal coated
Prostheses List by Category, Groups and Sponsor Page 24 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
BT067 Selox JT Fractal coated steroid electrode 45 and 53cm lengths $1,248.00
Guidant Australia Pty Ltd
GU009 Fineline II Sterox IROX Lead Model 4458, Model 4459 52cm, 58cm $1,248.00
GU011 Fineline II Sterox IROX Lead Model 4456, Model 4457 52cm, 58cm $1,248.00
GU012 Fineline II Sterox IROX Lead Model 4479, Model 4480 45cm, 52cm $1,248.00
GU023 Guidant Aust Selute Picotip Steroid Model 4033, Model 4034, Model 4035, 45cm , 52cm, 59cm $1,248.00
Eluting Bipolar Lead Model 4063, Model 4064
Medtronic Australasia Pty Ltd
MC010 Medtronic Capsure SP Novus Model Silicone Polyurethane 45 -110cm $1,144.00
5092; Capsure SP Novus Lead Model
5592; Medtronic Capsure Model 4023
Lead; Medtronic Capsure Model 4024
Lead (med.dexamethasone) Medtronic
Capsure Model 4523(MED) Medtronic
Capsure Model 4524 Lead; Medtronic
Capsure Model 5023M Lead; Medtronic
Model 5024M Capsure Lead; Medtronic
Model 5024M Capsure Lead; Medtronic
Capsure Model 5524M SP Bipolar Lead
MC229 Medtronic Capsure SP Novus Model Silicone, platinum 30-100cm $1,144.00
5594 Lead 30cm
MC336 Medtronic Capsure Z Novus Model Silicone; Contents: 1 x lead with 45-58cm $1,248.00
5054 Pacing Lead anchoring sleeve, stylet & guide, 1 x vein
lifter, 2 x fixation tools, extra stylets
MC337 Medtronic Capsure Z Novus Model Silicone; Contents: 1 x lead with 45-58cm $1,248.00
5554 Pacing Lead anchoring sleeve, stylet & guide, 1 x vein
lifter, 2 x fixation tools, extra stylets
MC371 Medtronic Capsurefix Model 6940 Silicone Polyurethane 30 - 85cm $1,144.00
Pacing Lead; Medtronic Tined IS-1
Model 4557M; Medtronic Capsurefix
Model 4067/8/4568 Pacing Leads;
Medtronic Capsurefix Model 5067
Pacing Leads; Medtronic Capsurefix
Model 5068 Pacing Leads; Capsure SP
Novus Pacing Lead Model 4092;
MC372 CapSure Sense pacemaker lead Models Titanium Nitride CapSure Sense Lead Model $1,248.00
4074 & 4574 4074 - 30cm to 85cm; CapSure
Sense Lead Model 4574 - 30cm
Prostheses List by Category, Groups and Sponsor Page 25 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
St. Jude Medical Australia Pty Ltd
SJ024 PASSIVE PLUS DX 1342T, 1343K, Single, passive fixation, steroid eluting, 46-58cm $1,248.00
1345K, 1346T low polarisation lead; Models: Bipolar
Atrial Lead, IS-1 Unipolar Atrial Lead, IS-
1 Unipolar Ventricular Lead, IS-1 or
Bipolar Ventricular Lead, IS-1
SJ082 Isoflex S, Models 1646T, 1642T and endocardial, Steroid Eluting, Silicone, 34cm, 40cm, 46cm, 52cm, $1,248.00
Passive Fixation Pacing Leads with Fast- 58cm, 85cm, 7F, 120cm 8F
Pass Coating
SJ097 Isoflex P 1644T and 1648T Endocardial, Steroid Eluting, 1648T - 34-85cm 1644T - 34- $1,248.00
Polyurethane, Passive-Fixation Bipolar
Pacing Leads with Fast-Pass Coating
Group 9 - Transvenous, Bi-Polar, Active, Steroid, Right Ventricular/Atrial
Biotronik Australia Pty Ltd
BT063 Selox SR Lead, pacemaker, implantable, 45, 53, 60cm length $1,248.00
BT083 Setrox S Bipolar active fixation lead with fractal length 45, 53, 60cm $1,248.00
coated and steroid eluting electrode
BT097 Dextrus (marketed by Boston Scientific) Bipolar, silicone, active fixation, steroid 7Fr, with 45cm, 53cm and $1,248.00
eluting, pacing lead 60cm length options
Guidant Australia Pty Ltd
GU013 Fineline II EZ Sterox IROX Lead Model 4472, Model 4473 & Model 4474 45cm, 52cm, 58cm $1,248.00
GU016 Fineline II EZ Sterox IROX Lead Model 4469, Model 4470 & Model 4471 45cm, 52cm, 58cm $1,248.00
GU122 Flextend Lead Models 4086, 4087 & Bipolar, steroid eluting, transvenous 45,52,59cm $1,248.00
silicon pace/sense leads with an
extendable/retractable active fixation for
implantation into the atrium or ventricle
Medtronic Australasia Pty Ltd
MC008 Medtronic Capsurefix Model 5568 Silicone Polyurethane 30 - 85cm $1,144.00
Pacing Leads
MC338 Medtronic Capsurefix Novus Model Silicone; Contents: 1 x lead with 45-85cm $1,248.00
5076 Pacing Lead anchoring sleeve, stylet & guide, 1 x vein
lifter, 2 x fixation tools, extra stylets
St. Jude Medical Australia Pty Ltd
SJ023 TENDRIL SDX 1488T, 1388T Single, Active Fixation, Steroid Eluting, 46cm-58cm $1,248.00
Low Polarisation Lead, IS-1
Prostheses List by Category, Groups and Sponsor Page 26 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
SJ073 Tendril SDX Models 1688T and Endocardial Steroid-Eluting Active 100cm, 25cm, 34cm, 40cm, $1,248.00
Fixation Pacing Lead 46cm, 52cm, 58cm, 85cm, 7F
Recorders, Long Term, ECG, Implantable
Medtronic Australasia Pty Ltd
MC028 Medtronic Reveal ILR Model 9525, Titanium 8cc $3,635.00
Implantable Cardiogram Recorder;
Reveal Plus Implantable Loop Recorder
Model 9526
Single Chamber ICDs
Generation 2
Biotronik Australia Pty Ltd
BT054 Lexos VR Single chamber ICD, Rate responsive One size only. $36,400.00
Progressive Medical
PG001 Alto II VR Single Chamber ICD Debrillator, implantable, automatic $36,400.00
Generation 3
Biotronik Australia Pty Ltd
BT075 Lumos VR-T Single Chamber ICD with home one size only $40,560.00
monitoring and IEGM online
BT087 Lumax 300 VR-T ICD-VR with bidirectional Home One Size Only $40,560.00
Monitoring. Single chamber
Guidant Australia Pty Ltd
GU110 Ventak Prizm II VR Model 1860, titanium, single chamber, One size only $40,560.00
adaptive rate
GU133 Vitality VR Model 1870 This device acts to defibrillate the heart Model 1870 Vitality VR Single $40,560.00
chambers when the patient enters into an Chamber Rate Responsive
arrhythmia or uses shocks or anti tachy Pacemaker/Defibrillator
pacing to revert Ventricular Tachycardia
(VT) or Ventricular Fibrillation (VF).
While also acting as a single chamber
GU148 Vitality 2 EL VR - Model T177 Implantable Cardiac Defibrillator 35cc 90g $40,560.00
Prostheses List by Category, Groups and Sponsor Page 27 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
GU151 Vitality 2 VR - Model T 175 Implantable cardiac defibrillator 30cc; 82g $40,560.00
Medtronic Australasia Pty Ltd
MC365 EnTrust Model D153VRC, Single chamber, 30J 33cc, 63g $40,560.00
Progressive Medical
PG008 OVATIO VR 6250 Titanium, single chamber, sterile, VR 29cc $40,560.00
6250, 34J
St. Jude Medical Australia Pty Ltd
SJ048 Epic Plus VR Model V-196 Implantable Single Chamber sensing and bradycardia 32cc $40,560.00
Cardioverter Defibrillator pacing
SJ093 Epic II VR V-158 Implantable Cardiac Single Chamber Cardioverter Defibrillator 34cc, 70g $40,560.00
Defibrillator
Single Chamber Pacemakers
Generation 1
St. Jude Medical Australia Pty Ltd
SJ053 Verity Adx Model XL SC 5056 Single Chamber multi-programmable rate- 10.5cc, 23g $4,264.00
implantable pacemaker adaptive pacing device with extended
longevity
Generation 2
St. Jude Medical Australia Pty Ltd
SJ076 Verity Adx Model XL SR 5157 M/S Single Chamber multi-programmable 11cc, 23g $5,928.00
implantable pacemaker rate-adaptive pacing devices with
extended longevity
Generation 3
Biotronik Australia Pty Ltd
BT046 Protos VR/CLS Single chamber rate responsive, closed One size only $5,928.00
loop system.
BT062 Philos II SR Multiprogrammable, Rate Responsive, One size only $5,928.00
SSIR pacemaker
BT080 Cylos VR single chamber dual sensor rate responsive one size only $5,700.00
Prostheses List by Category, Groups and Sponsor Page 28 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Boston Scientific Australia Pty Ltd
BS124 Insignia AVT 1192 Single chamber pacemaker 10cc, 23.4g $6,000.00
Guidant Australia Pty Ltd
GU124 Insignia Entra SR Models 1195 & 1198 Single Chamber Rate Responsive One size only $5,928.00
Permanent Pacemaker
GU126 Insignia Plus SR Model 1194 Single Chamber Rate Responsive One size only $5,928.00
Permanent Pacemaker
GU139 Insignia Ultra SR Lodel 1190 Implantable Cardiac Pacemaker One size only $5,928.00
Medtronic Australasia Pty Ltd
MC321 EnPulse SR Series: Model E2SR01, EnPulse SR - Pacemakers - with IS1 One size only $6,000.00
Model E2SR03, Model E2SR06 connector; with 3.2mm low profile
connector; with 5mm connector.
MC728 Adapta Pacemaker SR Pacemaker 9.7 - 11.0cc $5,928.00 $6,188.00
Models ADSR01, ADSR06, ADSR03 21.5 - 22.5g
Progressive Medical
PG006 Symphony SR Titanium one size only $5,928.00
St. Jude Medical Australia Pty Ltd
SJ055 Integrity ADx Model SR 5160 Single Chamber multi-programmable rate- 8cc, 17g $5,928.00
implantable pacemaker adaptive pacing device
SJ060 Identity ADx Model SR 5180 Single Chamber multi-programmable rate- 8cc, 18g $5,928.00
implantable pacemaker adaptive pacing device
SJ077 Verity Adx Models XL SR 5156 Single Chamber multi-programmable 11cc, 23g $5,928.00
implantable pacemaker rate-adaptive pacing devices with
extended longevity
SJ090 Victory SR 5610 single chamber rate responsive 41x44x46mm 17g 8cc $5,928.00
SJ105 Zephyr SR 5620 Single Chamber Rate-Responsive 8cc, 17g $5,928.00
Special Implantable Cardioverter Defibrillator Leads
Group 2 - Subcutaneous Leads
Guidant Australia Pty Ltd
GU123 Endotak SQ Array XP Lead Model 0085 Endotak SQ Array XP Lead Model 0085 70 cm $4,680.00
is used in addition to an Endotak
endocardial leads for patients with a high
DFT (Defibrillation Threshold)
Prostheses List by Category, Groups and Sponsor Page 29 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Medtronic Australasia Pty Ltd
MC251 Implantable Subcutaneous Defibrillator Silicone and Platinum Alloy Lengths 41-85cm inclusive $4,680.00
Lead Model 6996SQ 41cm, 58cm,
Group 7 - Epicardial Patches
Medtronic Australasia Pty Ltd
MC027 Model 6721 Unipolar Epicardial Patch Model 6721S-50, Model 6721M-50, 370, 660, 840mm $2,340.00
Leads S/M/L Model 6721L-50; Silicone
Special Purpose Dual Chamber Pacemaker - Custom Header
Generation 3
Medtronic Australasia Pty Ltd
MC241 Medtronic Kappa Pacemaker Model Cardiac Pacemaker, Titanium 13.9cc $9,048.00
KDR 933
MC332 Medtronic Kappa Pacemaker KDR 903 Cardiac Pacemaker, Titanium 13cc, 14.2cc $9,048.00
and KDR 906
MC340 Medtronic Kappa 400 pacemaker Model Titanium 13.9cc $9,048.00
KDR403
Special Purpose ICDs - High energy products
Generation 2
Guidant Australia Pty Ltd
GU107 Ventak Prizm HE DR Model 1853 & Model 1858, titanium, dual One size only $40,560.00
chamber, adaptive rate
Generation 3
Biotronik Australia Pty Ltd
BT074 Xelos DR-T High energy ICD with home monitoring. Packed in one small size $45,760.00
Dual chamber
BT086 Lumax 340 DR-T ICD-DR 34 J with bidirectional Home One Size Only $45,760.00
Monitoring. Dual chamber
BT090 Lumax 340 VR-T ICD-VR 34 J with bidirectional Home One size only $42,640.00
Monitoring. Single chamber
Prostheses List by Category, Groups and Sponsor Page 30 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Medtronic Australasia Pty Ltd
MC362 EnTrust Model D154DRG, dual chamber, VT 35cc, 68g $45,760.00
Therapies, 35J
MC366 EnTrust Model D154VRC, Single chamber, 35J 35cc, 68g $42,640.00
MC722 Virtuoso VR Model 37cc, 68g $42,640.00
Implantable Cardioverter Defibrillator,
Single Chamber
St. Jude Medical Australia Pty Ltd
SJ011 Atlas DR Model V-240 Dual chamber implantable cardioverter 37cc $45,760.00
defibrillator with rate response
SJ012 Atlas VR Model V-199 Single chamber implantable cardioverter 36cc $42,588.00
defibrillator with rate response
SJ063 Atlas DR Model V-242 ICD Implantable Dual Chamber Cardio-verter 38cc/78g $45,760.00
Defibrillator
SJ065 Atlas + VR Model V-193 ICD Single chamber implantable cardio-verter 38cc, 77g $42,640.00
defibrillator
SJ066 Atlas + VR - C Model V-193C ICD Single chamber implantable cardio-verter 38cc, 77g $42,640.00
defibrillator
SJ068 Atlas + DR Model V-243 ICD Implantable Dual Chamber Cardio-verter 38cc, 78g $45,760.00
Defibrillator
SJ114 Atlas II VR-168 Single chamber cardioverter defibrillator 38cc, 77g $42,640.00
SJ115 Atlas II+ DR V-268 Dual Chamber Cardioverter Defibrillator 39cc, 78g $45,760.00
Special Purpose ICDs - With therapies for Atrial Tachyarrhythmia
Generation 3
Guidant Australia Pty Ltd
GU137 Vitality AVT Dual chamber defibrillator, with atrial and One size only $45,760.00
ventricular therapy
GU157 Vitality AVT - Model A155 Implantable cardiac defibrillator with both 30cc $45,760.00
Atrial and Ventricular tachyarrhythmia
therapy
Medtronic Australasia Pty Ltd
MC349 Entrust Model D 153ATG, Dual chamber, AT 33cc, 63g $45,760.00
Therapies, 30J
Prostheses List by Category, Groups and Sponsor Page 31 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
MC364 EnTrust Model D154ATG, Dual chamber, AT 35cc, 68g $45,760.00
Therapies, 35J
MC721 Virtuoso DR Model 37cc, 68g $45,760.00
Implantable Cardioverter Defibrillator,
Dual Chamber
Special Purpose ICDs with CRT - High energy products
Boston Scientific Australia Pty Ltd
BS114 Contak Renewal 4 RF CRT-D CRT-D with RF telemetry, IS-1 43cc, 90g $47,840.00
connector H239 High Energy
Generation 2
Biotronik Australia Pty Ltd
BT089 Lumax 340 HF-T CRT-D 34 J with bidirectional Home One Size Only $47,840.00
Monitoring
Guidant Australia Pty Ltd
GU144 Contak Renewal 4 HE CRT-D Model Implantable dual-chamber defibrillator one size only $47,840.00
H197, Model H199
Medtronic Australasia Pty Ltd
MC325 InSync Sentry Model 7298 Defibrillator, Titanium 40cc $50,000.00
MC720 Concerto CRT-D Implantable Cardioverter Defibrillator 38cc $50,000.00
with Cardiac Resynchronisation Therapy
St. Jude Medical Australia Pty Ltd
SJ064 Atlas + HF Model V - 341 ICD - Atlas + HF ICD is a cardioverter 40cc/81g $47,840.00
Defibrillator, Implantable, automatic, defibrillator with dual chamber (atrial and
dual-chamber RV) sensing and bradycardia Pacing with
ventricular resynchronisation therapy.
SJ109 Atlas II+ HF V-367 Cardiac Resynchronisation Therapy 41cc, 79g $47,840.00
Defibrillator with V-V Timing
Programmability
Prostheses List by Category, Groups and Sponsor Page 32 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Special Purpose ICDs with CRT - With therapies for Atrial
Generation 2
Guidant Australia Pty Ltd
GU154 Contak Renewal 4 AVT CRT -D - Implantable Cardioverter Defibrillator 37cc; 89g $50,960.00
Model M170 and M175 with Cardiac Resynchronisation Therapy
GU155 Contak Renewal 4 AVT HE CRT - D - Implantable Cardioverter Defibrillator 40cc; 89g $52,000.00
Model M177, M179 with cardiac resynchronisation Therapy
Special Purpose Pacemaker - Small size (<7cc) for pacing in infants
Generation 3
St. Jude Medical Australia Pty Ltd
SJ027 St Jude Medical Microny II SR+ Model Single Chamber Rate Responsive Volume 5.9cc, Weight 12.8gm $5,928.00
2525T Pacemaker
Special Purpose Pacemaker - with Therapies for Atrial
Generation 3
Medtronic Australasia Pty Ltd
MC200 Medtronic A/Asia AT500 DDDRP Titanium, silicone One size only, 14.9cc $11,440.00
Pacing System Model AT501
MC360 EnRhythm Model P150 1DR, Rate Responsive dual 21g, 13cc $11,440.00
chamber pacemaker with Anti-
Tachycardia functions: DDDRP
Special Purpose Pacemaker Leads - Catheter Delivered
Group 9 - Transvenous, Bi-Polar, Active, Steroid, Right Ventricular/Atrial
Medtronic Australasia Pty Ltd
MC301 Model 3830 PACING LEADS Active fixation pacemaker lead 59 - 75 cm $2,600.00
Composition: Insulation is polyurethane,
Electrodes are Titanium Nitride coated
Platinum, the screw is steriod-coated
Prostheses List by Category, Groups and Sponsor Page 33 of 725
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Special Purpose Pacemaker Leads - VDD Leads
Group 8 - Transvenous, Bi-Polar, Passive, Steroid, Right Ventricular/Atrial
Guidant Australia Pty Ltd
GU028 Guidant Aust Selute Picotip VDD Lead Model 4340, Model 4341, Model 4342 & $1,544.00
Model 4343
Medtronic Australasia Pty Ltd
MC052 Medtronic Capsure VDD2 Model 5038 Silicone; Contents: 1 x lead with 11.5cm, 13.5cm, 15.5cm $1,544.00
AV Pacing Lead anchoring sleeve, stylet & guide, 1 x vein
lifter, 2 x fixation tools, extra stylets
Special Purpose Single Chamber Pacemaker - Custom Header
Generation 3
Medtronic Australasia Pty Ltd
MC030 Medtronic Kappa 400 Pacemaker Model Titanium 11.6cc, 11.7cc $5,616.00
KSR401
MC242 Medtronic Kappa KSR 900 Model KSR Cardiac Pacemaker, Titanium 9.7,10.5,11.0 cc $5,928.00
901,903, 906
MC330 Medtronic Kappa 400 Pacemaker Model Titanium 11.6cc, 11.7cc $5,616.00
KSR 403
Prostheses List by Category, Groups and Sponsor Page 34 of 725
EAR, NOSE & THROAT
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Cannulae, Eye, Lacrimal
Device Technologies Australia Pty Ltd
DE191 Canaliculus Intubation Sets Silicone, SS & Nylon 17.7 x .064 x 29cm, 15.5 x .051 $165.00
x 33cm
Caps, Bone
Cochlear Limited
CO028 BAHA - Bone Anchored Hearing Aids Cover screw unigrip One size only $364.00
Cement
Endotherapeutics Pty Ltd
ET031 Serenocem Cement Reaction bonded polymer composite One size only - box of 2 $1,560.00
formed by the neutralisation gelletation of
a basic inorganic ionomer
ET032 Serenocem Granules Reaction bonded polymer composite 0.5 - 1mm granules, 1gm or $1,070.00
formed by the neutralisation gelletation of 5gm; 2 - 3mm granules, 1gm or
a basic inorganic ionomer 5gm - 3 pouches
Cochlear Implants
Cochlear Limited
CO017 SPrint Speech Processor Consists of: SPrint Speech Processor - Processor: One Size Only, $4,282.25
body worn speech processor to suit Transmit Cable, 8-28cm,
BA055 Vitacuff, Hickman Triple Catheters Silicone, with VitaCuff 13.5 French Catheter $506.00 $521.18
BA126 Groshong Catheter Single Lumen, Sizes 5fr-9.5fr Groshong Dual Lumen, sizes 5fr-9.5fr $376.00 $387.28
Valved-Closed ended catheter
BA140 HemoGlide Long Term Haemodialysis Kit contents: 14.5fr catheter, 18g 15, 19, 23 & 27cm straight kit; $357.00 $367.71
Catheter guidewire introducer needle, 0.038" 70cm 19 & 23cm Pre-curved kit; 19,
J-wire guidewire, 15fr PTFE introducer 24 & 28cm and 31cm Pre-
sheath, 8" tunnelling device, 10-12fr curved jugular kit.
dualator vessel dilator, 2 adhesive
dressings, 2 injections caps, silicone
attachable suture wing, heparin label and
BA159 HemoSplit Long Term Haemodialysis HemoSplit is a carbothane long term dual Standard Kit (straight15cm $485.00 $499.55
catheter lumen catheter used to provide vascular to42cm and pre-curved 19cm
access for haemodialysis. It comprises of to31cm), Microintroducer Kits
a double D lumen configuration catheter (straight 19cm to 42cm & pre-
each lumen having an ID of 2.3mm) with curved 19cm to 31cm)
a fixed split tip (to 7.5cmm) which
enables blood flow rates as high as
500mls/minute. The catheter shaft has a
tissue ingrowth cuff to assist tissue
anchoring.
m
Bard Australia Pty Ltd
BA130 Vascular Catheter PICC- may include a Groshong Valved - Dual Lumen 4Fr - 7Fr $211.00 $217.33
Closed ended PICC, Single Lumen 4Fr-
Prostheses List by Category, Groups and Sponsor Page 721 of 725
VASCULAR
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
BA169 Poly RadPICC Catheters Double Lumen open-ended Polyurethane 4, 5, 6Fr with 70cm guide wire $149.00 $153.47 Temporary approval pending
review of catheters
BA170 Poly RadPICC Catheters Double Lumen open-ended Polyurethane 5, 6Fr with 135cm guide wire $149.00 $153.47 Temporary approval pending
review of catheters
William A Cook Australia Pty Ltd
WC205 Cook Central Venous Catheterisation Turbo-Flo Over-The Wire Peripherally 5Fr - 60cm $159.00
Inserted Central Venous Catheter Set,
Dual Lumen Polyurethane with
Micropuncture Peel-Away Sheath
Group 9c - Infuser Ports - single chamber
Tuta Healthcare Pty Ltd
TT001 Paragon Ambulatory Drug Infusion The top of the Paragon infuser is made of Infuser - 100mL Administration $988.00
acetyl with stainless steel parts; the Sets - 0.50mL, 1mL, 2mL,
bottom is made of clear polycarbonate. 4mL, 10mL, 50mL, 100mL, or
Diam: 10cm Height: 5.8cm.
Administration Sets - made from PVC
TT003 Sidekick Ambulatory Disposable Spring infusor made from high impact Infuser - 50mL or 100mL, $467.00
Delivery System plastics. Administration Sets - made Administration Sets - 50mL,
from PVC and acrylic components. 100mL or 200mL/hr
m
B Braun Australia Pty Ltd
BB170 Celsite Access Port for pain relief Composition - polysulphone. Kit includes Diameter of septum:11.7mm. $495.00
tunnelling rod, filter, connectors, Height: 11.5mm. Dimension:
needles, syringe, tuohy needle 25.8 x 37.8mm
Bard Australia Pty Ltd
BA056 Subcutaneous Ports Hickman open-ended catheter, single 8 - 9.6 French Catheter $500.00 $715.00
BA057 Groshong Subcutaneous Ports Single or dual lumen catheter 8 - 9.6 French Catheter $521.00 $727.00
BA060 Hickman Subcutaneous Ports Low-Profile 6 - 6.6 French Catheter $653.00 $672.59
BA177 SlimPort Ultra Low Profile Implanted Ultra SlimPort Low Profile Port: 16.9 x 22.7mm (W) x $541.00 $615.00
Plastic/Titanium port with attachable 9.2mm (H); 2.9g Wt 6 Fr
Chronoflex® single lumen catheter
William A Cook Australia Pty Ltd
WC093 Cook Implantable Injection/Infusion Petite or Standard, single or multiple 3 - 12 Fr pre-attached or $500.00
chamber Polysulfone Port which may detached catheter or valve system
include micropuncture or standard
Prostheses List by Category, Groups and Sponsor Page 722 of 725
VASCULAR
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
WC094 Cook Implantable Injection/Infusion Mini or Petite or Standard, single or 3 - 12 Fr pre-attached or $534.00
multiple chamber titanium Port which detached catheter or valve system
may include micropuncture or standard
WC115 Cook Implantable Injection/Infusion Mini, single or multiple chamber titanium 3 - 12 Fr pre-attached or $652.00
Port which may include micropuncture detached catheter or valve system
introducer set
Group 9d - Infuser Ports - multiple chambers
m
Bard Australia Pty Ltd
BA059 Dual Lumen Subcutaneous Ports Silicone, Polyurethane or ChronoFlex 7 - 10 French Catheter $805.00 $829.15
Open-ended Catheter
William A Cook Australia Pty Ltd
WC164 Cook Implantable Injection/Infusion Dual or Multiple Chamber Titanium Port 3 - 12 Fr pre-attached or $762.00
which may include micropuncture or detached catheter or valve system
standard introducer set
Internal embolization, intravascular
Ackermann Australia Pty Ltd
AK001 Haemostatic Ligating Clips Titanium Ligating Clips small - large $7.80
Device Technologies Australia Pty Ltd
DE275 DC Bead Drug delivery embolisation system 100-300, 300-500, 500-700, $1,650.00 $1,950.00 Product only to be used for
700-900 (microns) embolic procedures.
Matrix 2 - Prosthesis, internal, embolization, intravascular
Boston Scientific Australia Pty Ltd
BS100 Matrix Detachable Coils Platinum/Tungsten alloy coils covered Length: 2cm to 40cm, Diameter: $1,850.00
with an absorbable PGLA copolymer 2mm to 24mm
(90% Polyglycolic acid/ 10% Polylactic
Prostheses List by Category, Groups and Sponsor Page 723 of 725
VASCULAR
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Micrus Presidio Cerecyte Coil (PC4)
Medtel Australia Pty Ltd
ME183 Micrus Presidio Microcoil Sterile, single use, embolic coil used for 11.5-50cm (length) $1,850.00 $2,700.00
the treatment of cerebral aneurysms
Nexus Detachable Coil - Prosthesis, internal, embolization,
ev3 Australia Pty Ltd
EE007 Nexus Detachable Coils Nexus Tetris Diam 3-19mm, Length 4-29cm $1,850.00
EE008 Nexus Detachable Coils Multi Diameter Diam 4-10mm / Length 10- $1,250.00
EE017 Nexus Detachable Coil Helix Diameter 2-10mm / Length 1 - $1,250.00
30cm
Prosthesis, internal, embolization, intravascular
Boston Scientific Australia Pty Ltd
BS080 Matrix SR Detachable Coils Matrix SR Detachable Coils are Length: 2cm to 30cm, Diameter: $1,850.00
Platinum/Tungsten alloy coils covered 2mm to 10mm
with an absorbable PGLA copolymer
(90% Poly-glycolic acid/ 10% Poly-lactic
Prosthesis, internal, stent, vascular
Boston Scientific Australia Pty Ltd
BS079 Neuroform 2 Microdelivery Stent Self-expanding nitinol stent, 3fr delivery Diameter: 2.5-4.5mm, Length: $7,500.00
catheter, peelable sheath, 2fr stabilising 10mm-30mm
catheter, rotating haemostasis valve (x2)
Prostheses List by Category, Groups and Sponsor Page 724 of 725
VASCULAR
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
TRUFILL DCS ORBIT Detachable Coil - Embolization implant kit
Johnson & Johnson Medical Pty Ltd
JJ485 Trufill DCS Orbit detachable coil Helical Fill 2mm - 12mm, 2cm - 30cm $1,400.00
JJ486 Trufill DCS Orbit detachable coil Complex Standard 6mm - 20mm, 15cm - 30cm $1,505.00
Grand Total: 9162 Records
Prostheses List by Category, Groups and Sponsor Page 725 of 725
PART B - Human Tissue List December 2007
CARDIO-THORACIC
Billing Code Facility Minimum Benefit Maximum Benefit
Aortic Valved Conduit Patch
QHV09 The Prince Charles Hospital - Queensland Heart Valve Bank $4,706.00
Arterial Graft/Conduit
SHV03 Sydney Heart Valve Bank, St. Vincent's Hospital $987.00
Heart Valve - Aortic
QHV01 The Prince Charles Hospital - Queensland Heart Valve Bank $4,706.00
RPH01 Royal Perth Hospital T/A Heart Valve Bank $3,833.00
SHV01 Sydney Heart Valve Bank, St. Vincent's Hospital $5,350.00
TBV01 Donor Tissue Bank of Victoria $5,923.00
Heart Valve - Pulmonary
QHV02 The Prince Charles Hospital - Queensland Heart Valve Bank $4,706.00
RPH02 Royal Perth Hospital T/A Heart Valve Bank $3,833.00
SHV02 Sydney Heart Valve Bank, St. Vincent's Hospital $5,350.00
TBV02 Donor Tissue Bank of Victoria $5,923.00
Mitral Valve Patch
QHV03 The Prince Charles Hospital - Queensland Heart Valve Bank $985.00
Pericardium
TBV50 Donor Tissue Bank of Victoria $440.00
Pericardium Patch
QHV05 The Prince Charles Hospital - Queensland Heart Valve Bank $985.00
Pulmonary Conduit
TBV03 Donor Tissue Bank of Victoria $909.00
Pulmonary Conduit - Large
QHV07 The Prince Charles Hospital - Queensland Heart Valve Bank $985.00
Pulmonary Conduit - Small
QHV06 The Prince Charles Hospital - Queensland Heart Valve Bank $985.00
Pulmonary Valved Conduit For Patch use
QHV08 The Prince Charles Hospital - Queensland Heart Valve Bank $4,706.00
Page 1 of 15
CARDIO-THORACIC
Billing Code Facility Minimum Benefit Maximum Benefit
Tricuspid Valve Patch
QHV04 The Prince Charles Hospital - Queensland Heart Valve Bank $985.00
Amnion Corneal Graft
AUB01 Australian Biotechnologies $800.00
Cornea
LEM01 Lions Eye Donation Service $1,747.00
LEN01 Lions Eye Bank of NSW, Sydney Hospital $1,000.00
LEW01 Lions Eye Bank of Western Australia $2,000.00
QEB01 Queensland Eye Bank $1,345.00
SAE01 The Eye Bank of South Australia $840.00
TBV04 Donor Tissue Bank of Victoria $800.00
Cornea For Lamellar
LEN03 Lions Eye Bank of NSW, Sydney Hospital $600.00
Cornea for Sclera
LEM02 Lions Eye Donation Service $150.00
LEN02 Lions Eye Bank of NSW, Sydney Hospital $150.00
SAE02 The Eye Bank of South Australia $60.00
Human Amniotic Membrane for Transplantation
LEM03 Lions Eye Donation Service $770.00
SCLERA
LEW02 Lions Eye Bank of Western Australia $200.00
QEB02 Queensland Eye Bank $230.00
Achilles Tendon
NBB01 New South Wales Bone Bank $1,560.00
PBT01 Perth Bone and Tissue Bank $2,000.00
QBB01 The Queensland Bone Bank $1,745.00
TBV05 Donor Tissue Bank of Victoria $904.00
Achilles Tendon - Machined Conical Bone Plug
NBB69 New South Wales Bone Bank $2,425.00
Achilles Tendon with Bone Plug
NBB02 New South Wales Bone Bank $1,995.00
Page 2 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
TBV06 Donor Tissue Bank of Victoria $1,841.00
Anterior Cruciate Ligament Unit
PBT02 Perth Bone and Tissue Bank $1,700.00
Anterior Tibialis Tendon
NBB67 New South Wales Bone Bank $2,000.00
Autologous Chondrocyte Transplantation
MTE01 Mercy Tissue Engineering Pty Ltd $9,996.00
MTE03 Mercy Tissue Engineering Pty Ltd $11,349.00
MVS22 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $9,538.00
VAP01 Verigen Australia Pty Ltd $9,556.00
Autologous Chondrocytes
MTE02 Mercy Tissue Engineering Pty Ltd $2,509.00
VAP03 Verigen Australia Pty Ltd $2,593.00
Autologous Chondrocytes Implant and Matrix
ORT01 Orthogen Australia Pty Ltd $11,400.00
Autologous Skull Flap
MVS23 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $1,396.00
Bone - Chips/cubes 40cc
TBV09 Donor Tissue Bank of Victoria $874.00
Bone - Chips/cubes 80cc
TBV10 Donor Tissue Bank of Victoria $1,663.00
Bone Plug/Dowel - Cancellous
PBT03 Perth Bone and Tissue Bank $500.00
TBV07 Donor Tissue Bank of Victoria $610.00
Bone Plug/Dowel - Tricortical
TBV08 Donor Tissue Bank of Victoria $673.00
Cancellous Bone Matrix (CBM) - 40cc
TBV52 Victorian Institute of Forensic Medicine $556.00
Cancellous Bone Matrix (CBM) - 80cc
TBV53 Victorian Institute of Forensic Medicine $1,110.00
Cancellous Crunch - 15cc
Page 3 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
NBB62 New South Wales Bone Bank $835.00
Cancellous Crunch - 30cc
NBB61 New South Wales Bone Bank $1,523.00
Cancellous Crunch - 60cc
NBB60 New South Wales Bone Bank $2,310.00
Cartilage (costal) segments
PBT11 Perth Bone and Tissue Bank $300.00
QBB12 The Queensland Bone Bank $200.00
TBV17 Donor Tissue Bank of Victoria $350.00
Cortical Struts (Freeze Dried) 1 strut
QBB02 The Queensland Bone Bank $600.00
Cortical Struts (1 strut)
TBV14 Donor Tissue Bank of Victoria $685.00
Cortical Struts (2 struts)
TBV13 Donor Tissue Bank of Victoria $1,370.00
Cortical Struts 10-15cm
PBT06 Perth Bone and Tissue Bank $1,550.00
Cortical Struts>15 - 20cm
PBT07 Perth Bone and Tissue Bank $1,950.00
Cortical struts>20cm
PBT48 Perth Bone and Tissue Bank $2,200.00
Cortico - Cancellous Freeze Dried 20g
QBB03 The Queensland Bone Bank $1,925.00
Cortico-Cancellous Crunch (40/60) - 15cc
NBB65 New South Wales Bone Bank $835.00
Cortico-Cancellous Crunch (40/60) - 30cc
NBB64 New South Wales Bone Bank $1,523.00
Cortico-Cancellous Crunch (40/60) - 60cc
NBB63 New South Wales Bone Bank $2,310.00
Demineralised Bone Matrix - 10g
Page 4 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
TBV55 Donor Tissue Bank of Victoria $960.00
Demineralised Bone Matrix - 5g
TBV54 Donor Tissue Bank of Victoria $480.00
Disc - Freeze Dried
QBB04 The Queensland Bone Bank $650.00
Dowel Plug
NBB05 New South Wales Bone Bank $1,080.00
QBB13 The Queensland Bone Bank $1,188.00
Elbow - joint
QBB14 The Queensland Bone Bank $2,100.00
TBV18 Donor Tissue Bank of Victoria $4,710.00
Fascia Lata
TBV21 Donor Tissue Bank of Victoria $724.00
Fascia Lata - Large (15cm x 10cm)
PBT15 Perth Bone and Tissue Bank $1,400.00
Fascia Lata - Small (>10cm x >5cm)
NBB09 New South Wales Bone Bank $840.00
Fascia Lata - Small (10cm x 5cm)
PBT16 Perth Bone and Tissue Bank $800.00
Fascia Lata (per sq cm)
NBB08 New South Wales Bone Bank $4.00
QBB11 The Queensland Bone Bank $5.00
Femoral Condyle
PBT21 Perth Bone and Tissue Bank $1,900.00
Femoral Head
ACT01 ACT Bone Bank $1,638.00
APH01 The Avenue Private Hospital Bone Bank $1,131.00
CSA01 Rachel Forster Bone Bank $802.00
DHR01 Barwon Health $1,060.00
HBB01 The Hobart Private Hospital Bone Bank $1,400.00
LPH01 Lingard Private Hospital Bone Bank $1,103.00
Page 5 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
MMH01 Mater Misericordiae Hospital Bone Bank Theatres $400.00
MVS05 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $1,595.00
NBB16 New South Wales Bone Bank $1,750.00
PBT22 Perth Bone and Tissue Bank $1,900.00
QBB27 The Queensland Bone Bank $1,960.00
RNB01 Hunter New England Bone Bank $1,780.00
SVN01 Mater Hospital $731.00
TBV26 Donor Tissue Bank of Victoria $2,113.00
Femoral Head - Half (Freeze Dried)
QBB29 The Queensland Bone Bank $500.00
Femoral Head - Whole (Freeze Dried)
QBB28 The Queensland Bone Bank $800.00
Femoral Rings
NBB17 New South Wales Bone Bank $1,470.00
PBT24 Perth Bone and Tissue Bank $1,400.00
QBB30 The Queensland Bone Bank $1,445.00
Femoral Rings - (Freeze Dried)
QBB31 The Queensland Bone Bank $650.00
Femur - Cortical Portions < 15cm
QBB17 The Queensland Bone Bank $1,716.00
Femur - Cortical Portions > 15cm
QBB19 The Queensland Bone Bank $1,606.00
Femur - Distal (Shaft & Condyles)
MVS02 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
PBT17 Perth Bone and Tissue Bank $2,900.00
TBV22 Donor Tissue Bank of Victoria $3,460.00
Femur - Distal Half
NBB10 New South Wales Bone Bank $2,555.00
Femur - Distal half > 15cm
QBB20 The Queensland Bone Bank $2,555.00
Femur - Distal third
Page 6 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
NBB11 New South Wales Bone Bank $2,270.00
Femur - Distal third < 15cm
QBB21 The Queensland Bone Bank $2,456.00
Femur - Entire
MVS03 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB12 New South Wales Bone Bank $5,816.00
PBT18 Perth Bone and Tissue Bank $4,900.00
QBB22 The Queensland Bone Bank $3,870.00
TBV23 Donor Tissue Bank of Victoria $5,794.00
Femur - Hemicondyle
NBB59 New South Wales Bone Bank $2,100.00
Femur - Middle third
NBB13 New South Wales Bone Bank $2,250.00
QBB23 The Queensland Bone Bank $2,050.00
TBV24 Donor Tissue Bank of Victoria $1,887.00
Femur - Proximal (shaft, trochanter, neck)
MVS04 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
PBT20 Perth Bone and Tissue Bank $2,900.00
Femur - Proximal half
NBB15 New South Wales Bone Bank $2,755.00
Femur - Proximal half > 15cm
QBB25 The Queensland Bone Bank $2,755.00
Femur - Proximal third
NBB14 New South Wales Bone Bank $1,196.00
Femur - Proximal third < 15cm
QBB24 The Queensland Bone Bank $2,305.00
Femur - Proximal with femoral head
TBV51 Donor Tissue Bank of Victoria $3,332.00
Femur - Proximal without femoral head
TBV25 Donor Tissue Bank of Victoria $3,434.00
Femur - Segment
Page 7 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
NBB56 New South Wales Bone Bank $1,500.00
Femur - Shaft Half
NBB57 New South Wales Bone Bank $2,310.00
Femur - Shaft Third
NBB55 New South Wales Bone Bank $1,500.00
Femur - Trochanter Milled
QBB26 The Queensland Bone Bank $800.00
Femur- 1 Condyle only
TBV46 Donor Tissue Bank of Victoria $1,065.00
Fibula - Entire
MVS07 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB18 New South Wales Bone Bank $3,200.00
PBT25 Perth Bone and Tissue Bank $2,100.00
QBB32 The Queensland Bone Bank $2,405.00
TBV27 Donor Tissue Bank of Victoria $6,041.00
Fibula - Segment
NBB54 New South Wales Bone Bank $1,925.00
Fibula - Segment (12cm)
MVS14 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB20 New South Wales Bone Bank $1,881.00
TBV29 Donor Tissue Bank of Victoria $932.00
Fibula - Segment (6cm)
MVS13 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB19 New South Wales Bone Bank $1,300.00
TBV28 Donor Tissue Bank of Victoria $610.00
Fibula - Shaft
TBV30 Donor Tissue Bank of Victoria $1,968.00
Fibula segment (prox / distal)
PBT28 Perth Bone and Tissue Bank $1,200.00
Fibular Strut < 10cm:
QBB06 The Queensland Bone Bank $1,331.00
Page 8 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
Fibular Strut > 10cm:
QBB07 The Queensland Bone Bank $1,469.00
Freeze Dried Milled Bone <30gm
PBT37 Perth Bone and Tissue Bank $750.00
Freeze Dried Milled Bone 30 - 50gm
PBT38 Perth Bone and Tissue Bank $900.00
Freeze-dried Cancellous Cubes (6)
QBB09 The Queensland Bone Bank $1,469.00
Freeze-Dried Cancellous Strips (2)
QBB10 The Queensland Bone Bank $650.00
Hemipelvis - Acetabulum
NBB21 New South Wales Bone Bank $2,696.00
PBT29 Perth Bone and Tissue Bank $2,400.00
QBB33 The Queensland Bone Bank $2,505.00
TBV31 Donor Tissue Bank of Victoria $2,686.00
Hemipelvis - Complete
MVS08 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB24 New South Wales Bone Bank $6,116.00
PBT30 Perth Bone and Tissue Bank $4,500.00
QBB37 The Queensland Bone Bank $3,870.00
TBV32 Donor Tissue Bank of Victoria $6,093.00
Hemipelvis - IIliac crest
NBB22 New South Wales Bone Bank $2,321.00
PBT31 Perth Bone and Tissue Bank $1,100.00
QBB34 The Queensland Bone Bank $2,245.00
TBV33 Donor Tissue Bank of Victoria $2,428.00
Hemipelvis - Tricortical Iliac Wedge
QBB35 The Queensland Bone Bank $1,106.00
Hemipelvis - Tricortical Iliac Wedge (Freeze Dried
QBB36 The Queensland Bone Bank $700.00
Hemipelvis -Tricortical iliac wedge
Page 9 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
NBB23 New South Wales Bone Bank $1,005.00
PBT32 Perth Bone and Tissue Bank $600.00
TBV34 Donor Tissue Bank of Victoria $920.00
Humeral Head
QBB44 The Queensland Bone Bank $1,485.00
TBV37 Donor Tissue Bank of Victoria $1,484.00
Humeral Head Addition
NBB26 New South Wales Bone Bank $1,419.00
Humerus - Cortical portions/blocks < 10cm
QBB38 The Queensland Bone Bank $1,221.00
Humerus - Cortical portions/blocks > 10cm
QBB39 The Queensland Bone Bank $1,463.00
Humerus - Distal
MVS19 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
TBV49 Donor Tissue Bank of Victoria $1,979.00
Humerus - Distal half
NBB25 New South Wales Bone Bank $1,200.00
Humerus - Entire
MVS20 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB29 New South Wales Bone Bank $2,828.00
QBB43 The Queensland Bone Bank $2,755.00
Humerus - Proximal half
NBB27 New South Wales Bone Bank $1,658.00
QBB40 The Queensland Bone Bank $1,445.00
Humerus - Proximal half with rotator cuff
NBB28 New South Wales Bone Bank $2,500.00
QBB41 The Queensland Bone Bank $2,430.00
Humerus - Proximal with rotator cuff
MVS09 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
PBT34 Perth Bone and Tissue Bank $2,500.00
TBV35 Donor Tissue Bank of Victoria $2,336.00
Page 10 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
Humerus - Proximal w'out rotator cuff
PBT35 Perth Bone and Tissue Bank $1,100.00
QBB42 The Queensland Bone Bank $1,445.00
TBV36 Donor Tissue Bank of Victoria $2,485.00
Humerus - Ring
NBB53 New South Wales Bone Bank $1,300.00
Humerus - Segment
NBB52 New South Wales Bone Bank $1,400.00
Humerus - Shaft Half
NBB51 New South Wales Bone Bank $1,500.00
Humerus - Shaft Whole
NBB50 New South Wales Bone Bank $2,750.00
Humerus - Whole
PBT33 Perth Bone and Tissue Bank $3,000.00
Humerus - Whole with rotator cuff
NBB30 New South Wales Bone Bank $2,941.00
Medial Ligament
NBB31 New South Wales Bone Bank $1,529.00
TBV38 Donor Tissue Bank of Victoria $1,599.00
Meniscal Graft
PBT47 Perth Bone and Tissue Bank $1,800.00
Meniscus
QBB05 The Queensland Bone Bank $1,276.00
Meniscus with Ligaments
TBV39 Donor Tissue Bank of Victoria $1,927.00
Meniscus without Ligaments
TBV40 Donor Tissue Bank of Victoria $1,046.00
Milled Bone - 15cc
NBB58 New South Wales Bone Bank $756.00
Milled Bone - 30g
Page 11 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
NBB03 New South Wales Bone Bank $1,103.00
Milled Bone - 40cc
TBV11 Donor Tissue Bank of Victoria $1,046.00
Milled Bone - 60cc
QBB45 The Queensland Bone Bank $1,843.00
Milled Bone - 60g
NBB04 New South Wales Bone Bank $1,759.00
Milled Bone - 60g max
QBB46 The Queensland Bone Bank $1,200.00
Milled Bone - 80cc
TBV12 Donor Tissue Bank of Victoria $1,870.00
Milled Bone <30g
PBT08 Perth Bone and Tissue Bank $1,600.00
Milled Bone >50g
PBT10 Perth Bone and Tissue Bank $2,350.00
Milled Bone 30 - 50g
PBT09 Perth Bone and Tissue Bank $2,050.00
Patella
NBB32 New South Wales Bone Bank $875.00
QBB47 The Queensland Bone Bank $750.00
TBV41 Donor Tissue Bank of Victoria $915.00
Patella tendon
QBB48 The Queensland Bone Bank $1,900.00
Patella Tendon - Machined Conical Bone Plug
NBB68 New South Wales Bone Bank $1,925.00
Patella Tendon and Patella
TBV42 Donor Tissue Bank of Victoria $1,927.00
Patella tendon with Bone Plugs
NBB33 New South Wales Bone Bank $1,425.00
Patellar unit whole with tibial block
Page 12 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
PBT40 Perth Bone and Tissue Bank $2,100.00
Primary MACI plus 1/2
VAP02 Verigen Australia Pty Ltd $10,891.00
Radius
MVS18 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB06 New South Wales Bone Bank $2,673.00
PBT13 Perth Bone and Tissue Bank $1,800.00
QBB15 The Queensland Bone Bank $2,050.00
TBV19 Donor Tissue Bank of Victoria $2,796.00
Radius - Ring
NBB49 New South Wales Bone Bank $1,680.00
Radius - Segment
NBB48 New South Wales Bone Bank $1,925.00
Radius - Shaft
NBB47 New South Wales Bone Bank $2,750.00
Rib (5cm)
MVS21 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $382.00
PBT41 Perth Bone and Tissue Bank $300.00
TBV43 Donor Tissue Bank of Victoria $437.00
Scaphoid
QBB49 The Queensland Bone Bank $900.00
Semi Tendinosis Tendon
NBB70 New South Wales Bone Bank $2,000.00
Shaft - Femur / Tibia Middle third
PBT19 Perth Bone and Tissue Bank $2,500.00
Tibia - Condyles only
TBV47 Donor Tissue Bank of Victoria $1,491.00
Tibia - Cortical < 15cm
QBB50 The Queensland Bone Bank $1,405.00
Tibia - Cortical > 15 cm
QBB51 The Queensland Bone Bank $1,716.00
Page 13 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
Tibia - Distal
MVS17 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
TBV48 Donor Tissue Bank of Victoria $1,922.00
Tibia - Middle third seg
NBB34 New South Wales Bone Bank $1,400.00
QBB53 The Queensland Bone Bank $900.00
Tibia - Plateau (prox 1/3)
NBB35 New South Wales Bone Bank $2,065.00
Tibia - Proximal third < 15cm
QBB54 The Queensland Bone Bank $2,250.00
Tibia - Proximal third with Patella Tendon
QBB08 The Queensland Bone Bank $2,555.00
Tibia - Proximal with Patella Tendon
NBB46 New South Wales Bone Bank $3,647.00
Tibia - Proximal: without Patella
PBT45 Perth Bone and Tissue Bank $2,300.00
Tibia - Proximal: 16-25cm
TBV45 Donor Tissue Bank of Victoria $2,215.00
Tibia - Proximal: 7-15cm
TBV44 Donor Tissue Bank of Victoria $2,299.00
Tibia - Proximal: half
MVS11 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB36 New South Wales Bone Bank $2,290.00
Tibia - Proximal: with Patella & Tendon
PBT44 Perth Bone and Tissue Bank $2,900.00
Tibia - Ring
NBB45 New South Wales Bone Bank $1,300.00
Tibia - Shaft Half
NBB43 New South Wales Bone Bank $2,200.00
Tibia - Shaft Third
Page 14 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
NBB42 New South Wales Bone Bank $2,168.00
Tibia - Shaft Whole
NBB41 New South Wales Bone Bank $3,163.00
Tibia - Strut
QBB52 The Queensland Bone Bank $400.00
Tibia - Whole
MVS16 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB37 New South Wales Bone Bank $3,685.00
QBB55 The Queensland Bone Bank $3,870.00
Tibia - Whole with Patella Tendon
NBB44 New South Wales Bone Bank $5,042.00
Tibialis Tendon
PBT46 Perth Bone and Tissue Bank $1,450.00
Tri Cortical Osteotomy
NBB66 New South Wales Bone Bank $1,106.00
Ulna
MVS15 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB07 New South Wales Bone Bank $2,464.00
PBT14 Perth Bone and Tissue Bank $1,500.00
QBB16 The Queensland Bone Bank $2,050.00
TBV20 Donor Tissue Bank of Victoria $2,577.00
Ulna - Ring
NBB40 New South Wales Bone Bank $1,680.00
Ulna - Segment
NBB39 New South Wales Bone Bank $1,925.00
Ulna - Shaft
NBB38 New South Wales Bone Bank $2,200.00
Grand Total: 277 Records
Page 15 of 15
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