Private Health Insurance (Prostheses) Rules 2010 (No. 2) (Cth)
Private Health Insurance (Prostheses) Rules 2010
(No. 2)
As amended
Made under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.
This compilation was prepared on 19 January 2011 taking into account amendments up to the Private Health Insurance (Prostheses) Amendment Rules 2010 (No.2).
Prepared by the Department of Health and Ageing, Canberra.
Contents
Part 1 Preliminary 3
1.Name of Rules 3
2.Commencement 3
3.Revocation 3
4.Definitions 3
Part 2 Benefit requirements 5
5.Listing of, and benefits, for prostheses 5
6.Benefits for prostheses provided as part of hospital treatment 6
7.Benefits for prostheses provided as part of hospital-substitute treatment 6
8.Timing of applications to have a prosthesis listed 7
9.Minister may have regard to recommendations and advice 7
10.Listing criteria for prostheses to be listed on Part C of the Schedule 7
Part 1 Preliminary
Name of Rules
These Rules are the Private Health Insurance (Prostheses) Rules 2010 (No. 2).
Commencement
These Rules commence on 14 August 2010.
Revocation
These Rules revoke the Private Health Insurance (Prostheses) Rules 2010 (No. 1).
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.
certified overnight Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.
certified Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.
consultant physician has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.
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'.
implantable cardiac event recorder includes a component of an implantable cardiac event recorder.
insulin infusion pump includes a component of an insulin infusion pump.
listing application has the same meaning as in subsection 72-10(6) of the Act.
listing criteria has the same meaning as in subsection 72-10(6) of the Act.
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 attendance has the same meaning as in clause 1.2.3 of the Health Insurance (General Medical Services Table) Regulations 2010.
professional service has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.
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; or
(iii) for a prosthesis that is an insulin infusion pump:
(A)the insulin infusion pump is provided during a professional service for which a medicare benefit is payable; and
(B)the professional service is a professional attendance by a consultant physician in the practice of his or her specialty; and
(C)the professional service is provided as a certified Type C procedure or certified overnight Type C procedure; and
(D)the insulin infusion pump is provided for the purpose of administering insulin; 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; and
(d)rule 10 sets out listing criteria for the purposes of subsection 72-10(6) of the Act in relation to the granting of a listing application for listing of a kind of prosthesis on Part C of the Schedule.
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.
Listing criteria for prostheses to be listed on Part C of the Schedule
For a listing application to list a kind of prosthesis on Part C of the Schedule, the listing criteria are that the kind of prosthesis is an:
(i) insulin infusion pump; or
(ii) implantable cardiac event recorder.
Note: The Minister may refuse to grant a listing application even if the listing
criteria are satisfied.
Notes
The Private Health Insurance (Prostheses) Rules 2010 (No.2) as shown in this compilation are amended as indicated in the tables below.
Table of Instruments
| Instrument | Date of FRLI registration | Date of commencement | Application, saving or transitional provision |
| Private Health Insurance (Prostheses) Rules 2010 (No.2) | 30 July 2010 | 14 August 2010 | |
| Private Health Insurance (Prostheses) Amendment Rules 2010 (No.1) | 22 September 2010 | 5 October 2010 | |
| Private Health Insurance (Prostheses) Amendment Rules 2010 (No.2) | 13 January 2011 | 14 January 2011 |
Table of Amendments
| ad. = added or inserted am. = amended rep. = repealed rs. = repealed and substituted | |
| Provision affected | How affected |
| Rule 4 Rule 5(b)(ii) Rule 5(b)(iii) Rule 5(c) Rule 5(d) Rule 10 Schedule............................ | am. 2011 No. F2011L00092 am. 2011 No. F2011L00092 am. 2011 No. F2011L00092 rs. 2011 No. F2011L00092 ad. 2011 No. F2011L00092 ad. 2011 No. F2011L00092 am. 2010 No. F2010L02500, F2011L00092 |
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 List August 2010
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 1- Cardiothoracic Mechanical Valves
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
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
model 501DA advanced performance Polyester, Titanium
(AP) aortic valve series, ATS medical
open pivot heart valve model 501DM
advanced performance (AP) mitral valve
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, $6,000.00
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
Sorin Group
SA129 Optiform Mechanical Valve 19mm to 33mm $6,000.00
Prostheses List by Category, Groups and Sponsor Page 1 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
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
Group 1: Single Chamber ICD's
Generation 3
Guidant Australia Pty Ltd
GU148 Vitality 2 EL VR - Model T177 Single Chamber ICD 35cc; 90g $40,560.00
GU151 Vitality 2 VR - Model T 175 Single Chamber ICD 30cc; 82g $40,560.00
Sorin Group
SA139 OVATIO VR 6250 Titanium, single chamber, sterile, VR 29cc $40,560.00
6250, 34J
a
Sorin Group
SA149 PARADYM VR 8250 Single Chamber implantable cardioverter Dimensions: 58.4 x 73.4 x $42,640.00
defibrillator with rate response 11mm; Weight: 90 grams;
Prostheses List by Category, Groups and Sponsor Page 2 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
St. Jude Medical Australia Pty Ltd
SJ066 Atlas + VR - C Model V-193C ICD Single chamber implantable cardio-verter 38cc, 77g $42,640.00
defibrillator
SJ114 Atlas II VR-168 Single chamber cardioverter defibrillator 38cc, 77g $42,640.00
SJ121 Current VR 1107-36 Single Chamber Cardioverter Defibrillator 38cc 76g $42,640.00
a, d
St. Jude Medical Australia Pty Ltd
SJ142 Analyst VR CD1217-36 Single Chamber Cardioverter Defibrillator 79g, 41cc $42,640.00 $44,640.00
with RF Telemetry and ST Segment
Monitoring
A,C,D
Medtronic Australasia Pty Ltd
MC722 Virtuoso VR ModelImplantable Cardioverter 37cc, 68g $42,640.00
Defibrillator, Single Chamber
A,D
Biotronik Australia Pty Ltd
BT090 Lumax 340 VR-T ICD-VR 34 J with bidirectional Home One size only $42,640.00 $45,640.00
Monitoring. Single chamber
BT098 Lumax 340 VR-T XL ICD-VR with 40 J output, bidirectional One Size Only $42,640.00 $45,640.00
Home Monitoring and High Longevity
Boston Scientific Australia Pty Ltd
BS136 TELIGEN 100 HE VR DF-1/IS-1 Single chamber ICD, High Energy with RF 31.5cc, 9.9mm $42,640.00
Medtronic Australasia Pty Ltd
MC939 Virtuoso II VR Model - Implantable Cardioverter 37cc, 68g $42,640.00
Defibrillator, Single Chamber
St. Jude Medical Australia Pty Ltd
SJ124 Current RF VR 1207-36 Single Chamber Cardioverter Defibrillator 79g, 41cc $42,640.00
with RF Telemetry
A,D,E
Boston Scientific Australia Pty Ltd
BS132 Teligen 100 HE VR 4-SITE Single chamber ICD, high energy with 30.5cc, 9.9mm $43,390.00
Prostheses List by Category, Groups and Sponsor Page 3 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
D
Biotronik Australia Pty Ltd
BT087 Lumax 300 VR-T ICD-VR with bidirectional Home One Size Only $40,560.00 $43,560.00
Monitoring. Single chamber
St. Jude Medical Australia Pty Ltd
SJ216 AnalyST VR CD1217-30 Single chamber cardioverter defibrillator 73g, 37cc $40,560.00 $42,560.00
with RF telemetry and ST segment
Generation 4
a, d, e
St. Jude Medical Australia Pty Ltd
SJ232 Current Accel VR CD1215-36Q Single Chamber Cardioverter Defibrillator 80g, 42cc $44,670.00
with RF Telemetry and SJ4 connector
SJ237 AnalyST Accel VR CD1219-36Q Single Chamber Cardioverter Defibrillator 79g, 41cc $44,670.00
with RF Telemetry and ST Segment
Monitoring and SJ4 connector.
A,D
Biotronik Australia Pty Ltd
BT100 LUMAX 540 VR-T High Energy, Single-Chamber ICD Diamensions: 66*55*13 mm $43,920.00 $45,640.00
(Implantable Cardiac Defibrillator) with Volume/Weight : 37.2cc/92g
Advanced Patient Management Via unique
Home Monitoring Technology
incorporatin Automatic Threshold
Monitoring and Extended Longevity.
Medtronic Australasia Pty Ltd
MC813 Secura VR Fully Automatic, Wireless Implantable 37cc $43,920.00
cardioverter defibrillator with high energy
capability and therapies for ventricular
tachyarrhythmia
St. Jude Medical Australia Pty Ltd
SJ147 Current Accel VR RF CD1215-36 Single Chamber Cardioverter Defibrillator 79g, 38cc $43,920.00 $44,640.00
with RF Telemetry
SJ154 AnalyST Accel VR CD1219-36 Single Chamber Cardioverter Defibrillator 79g, 41cc $43,920.00 $44,640.00
with RF Telemetry and ST Segment
Monitoring
Prostheses List by Category, Groups and Sponsor Page 4 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
D
St. Jude Medical Australia Pty Ltd
SJ212 AnalyST Accel VR CD1219-30 Single chamber cardioverter defibrillator 73g, 37cc $41,820.00 $44,560.00
with RF telemetry and ST segment
SJ213 Current Accel VR RF CD1215-30 Single chamber cardioverter defibrillator 73g, 37cc $41,820.00 $44,560.00
with RF telemetry
Group 10: Pacemaker/ICD Extenders
Medtronic Australasia Pty Ltd
MC831 Medtronic Lead Extender Kit Model: Silicone 37 - 50cm $530.00
6984M, 6981M, 6985M,6986m
Group 11: Pacemaker/Lead Accessories
Medtronic Australasia Pty Ltd
MC036 Medtronic Lead End Cap Kit Model: Pin Plug Kits to Seal Unused Pacemaker One Size Per Model $80.00
5867-3M; Medtronic DF-1 Port Pin or Defibrillator Port; Sizing Sleeve -
Plug Kit: Model 6719, Medtronic IS-1 Silicone or Polyurethane
Port Pin Plug Kit: Model 6725;
Medtronic Upsizing Sleeve: Model 5866-
Group 12: Coronary Stents
Sub-Group 1: General Purpose Drug eluting stents
Abbott Australasia Pty Ltd
AY023 Xience Everolimus Eluting Stent System Everolimus Eluting Stent System 2.25mm to 4.0mm widths, 8mm $3,450.00
to 28mm lengths
Prostheses List by Category, Groups and Sponsor Page 5 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
AY037 Xience PRIME LL Everolimus Eluting Coronary Artery Stent, Drug Eluting XIENCE PRIME LL 2.50; 2.75; $3,450.00
Coronary Stent; Xience PRIME 3.00; 3.50; 4.0 x 33MM;
Everolimus Eluting Coronary Stent; XIENCE PRIME LL 2.50; 2.75;
Xience PRIME SV Everolimus Eluting 3.00; 3.50; 4.0 x 38MM;
XIENCE PRIME SV 2.25 x 08;
12; 15; 18; 23; 28MM; XIENCE
PRIME 2.50 x 08; 12; 15; 18;
23; 28MM; XIENCE PRIME
2.75 x 08; 12; 15; 18; 23;
28MM; XIENCE PRIME 3.00 x
08; 12; 15; 18; 23; 28MM;
XIENCE PRIME 3.50 x 08; 12;
15; 18; 23; 28MM; XIENCE
PRIME 4.00 x 08; 12; 15; 18;
23; 28MM
Boston Scientific Australia Pty Ltd
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 2.25mm to 4.0mm diameter, $3,450.00
a blended polymer mixed with Everolimus. 8mm to 28mm length
BS175 PROMUS Element Platinum chromium alloy stent coated 8mm to 38mm with a reference $3,450.00
with a blended polymer mixed with vessel diameter of 2.25mm -
4.0mm.
BS176 Taxus Element Platinum chromium alloy stent coated (8mm to 38mm) with a $3,450.00
with a blended polymer mixed with reference vessel diameter of
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, 2835
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,
Prostheses List by Category, Groups and Sponsor Page 6 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
MC769 Endeavor Sprint Drug Eluting Stent Cobals Alloym ABT - 578 Diameter: 2.25mm-4.0mm; $3,450.00
Length: 8.0mm-30.0mm
MC816 Endeavor Resolute Drug Eluting Cobalt Alloy, ABT - 578, BioLinx Diameter:2.25mm-4.0mm; $3,450.00
Coronary Stent System Length: 8.00mm-30.0mm
Sub-Group 2: 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
AY028 Multilink Coronary Stent System - Cobalt chrome stent 2.25mm to 4.0mm widths, 8mm $1,248.00
to 38mm lengths
Atrium Australia - Pacific Rim Pty Limited
AC030 Cinatra Cobalt Chromium Coronary The Cinatra Cobalt Chromium Coronary Diameter range: 2.5mm - $1,248.00 $1,372.00
Stent System Stent System consists of a balloon 3.5mm. Length range: 8mm -
expandable Cobalt Chromium stent
premounted on a rapid exchange system
Bio Excel Australia Pty Ltd
BE001 Gazelle Coronary Stent Stainless Steel Diam 2.25-4.0mm Length 8- $1,248.00
Biotronik Australia Pty Ltd
BT082 PRO-Kinetic Cobalth Chromium coronary stent system 8-40mm length 2-5mm diameter $1,200.00
Prostheses List by Category, Groups and Sponsor Page 7 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
BT107 PRO-Kinetic Energy The PRO-Kinetic Energey stent is a The PRO-Kinetic Energy stent is $1,248.00
tubular, balloon-expandable stent sculpted available in 66 different
by laser from a single tube of L-605 diameter/length combinations. It
cobalt chromium (CoCr) alloy. The stent is available in lengths from
consists of circular segments at each end 8mm to 40mm. It is
followed by a transition zone and premounted on a delivery
helicoidally arranged struts in the middle. system which has nominal
Each loop of the helix is connected to the balloon diameters between
next loop by 3 longitudinal struts. The 2.0mm and 5.0mm.
stent surface is fully coated with a layer
of amorphous hydrogen-rich silicon
carbide (aSiC:H). This material has
semiconducting properties that efficiently
prevent the electron transfer from
fibrinogen to the metal surface in vitro.
Thereby the conversion from fibrinogen
to fibrin and it's depoisition at the stent
surface is reduced. Additionally, aSiC:H -
coated stents exhibit a lower adhesion
and activation of blood platelets and
leucocytes. Finally, the release of
potentially allergenic ions from a silicon
carbide coated stent is substantially
reduced in comparison to an uncoated
metal stent3. This coating is used on all
Biotronik coronary stents producedso far
Boston Scientific Australia Pty Ltd
BS069 Liberte Coronary Stent System 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 &
Imaxeon Pty Ltd
IX001 Amazonia CroCo Balloon expandable intracoronary cobalt Lengths: 8mm, 12mm, 16mm, $1,248.00
chromium stent premounted onto a rapid 20mm, 24mm, 28mm, 32, 36,
exchange delivery catheter and 40mm. Diameters:
2.25mm, 2.5mm, 2.75mm,
3.0mm, 3.5mm, 4.0mm, 4.50
and 5.00 mm in all lengths
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
Prostheses List by Category, Groups and Sponsor Page 8 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
JJ239 BX Sonic Stainless steel coronary stent mounted on Dia 2.25 - 4.0mm, lengths 8 - $1,220.00
a balloon delivery system
JJ670 Presillion CoCr Coronary Stent on RX Cobalt Chromium, bare metal coronary Stent Length (mm) x Stent $1,248.00
System Diameter (mm) 8 x 2.50, 2.75,
3.0, 3.50, 4.0; 12 x 2.50, 2.75,
3.0, 3.50, 4.0; 17 x 2.50, 2.75,
3.0, 3.50, 4.0; 24 x 2.75, 3.0,
3.50, 4.0; 33 x 2.75, 3.0, 3.50,
Medtronic Australasia Pty Ltd
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 -
MC932 Driver Sprint Coronary Stent System Cobalt Alloy Diameter: 2.25 - 4.5 mm; $1,248.00
Length: 8-30mm
MC956 Integrity Coronary Stent System Cobalt Alloy Coronary Stent Diameter: 2.25 - 4.5mm; Length: $1,248.00
8 - 30mm
OrbusNeich 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
NM004 Blazer Coronary Stent Delivery System L605 Cobalt Chromium alloy balloon Expanded Stent Diameter 2.5 to $1,248.00
expandable vascular prosthesis 4.0mm, Stent Length 9 to 33mm
Terumo Corporation Australia
TU001 Tsunami Gold Stainless Steel mounted on balloon Diameter 2.0mm - 4.0mm, $1,248.00
Length 8mm - 30mm length
Sub-Group 3: Bare metal stents for specific indications
a, b
Abbott Australasia Pty Ltd
AY012 JoStent Coronary Stent Graft Stainless Steel/PTFE 9 - 26 mm x 2.5 - 5 mm $3,222.00
c.3
Imaxeon Pty Ltd
IX003 Minvasys Nile Delta Coronary Stent Balloon expandable Amazonia Nile Delta 2.50mm diameter x $1,248.00
intracoronary cobalt chromium stent 8mm length; Nile Delta 3.00mm
premounted onto a rapid exchange diameter x 8mm length
delivery catheter with tapered balloon.
Prostheses List by Category, Groups and Sponsor Page 9 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
C1
Abbott Australasia Pty Ltd
AY027 Multilink Coronary Stent System - 316L Stainless steel stent Length 1.5 - 8.0mm $2,200.00
C2
Imaxeon Pty Ltd
IX002 Nile CroCo Intracoronary stent pre-mounted on two Diameter : 2.50 - 3.50mm. MB $1,750.00
rapid exchange delivery systems for and 2.00-3.00mm SB
bifurcation lesions treatment Lengths 18 mm and 24 mm
Group 13: Special Purpose Percutaneous Cardiovascular Devices
Sub-Group 1: Intracardiac Defect Occluders
a
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
ME068 Amplatzer PFO Occluder Nitinol Wire Mesh 25mm & 35mm $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
ME187 AMPLATZER Duct Occluder II Self expandable multiple Nitinol wire Waist diameter 3-6mm, Nominal $10,200.00
mesh PDA occlusion device length 4-6mm
Pacing Importers Pty Ltd - Life Systems
PI020 'STARflex Rapid Transport Plus System The STARFlex Rapid Transport Plus 23mm, 28mm, 33mm and $10,200.00
System consists of two primary
components: 1) The device, a permanent
implant, which is constructed primarily of
a metal MP35N framework to which
polyester fabric is attached, and 2) The
delivery catheter, a Pebax based catheter
designed specifically to facilitate
attachment, loading, delivery and
deployment of the device to the defect.
The device and delivery catheter can be
packaged separately or pre-attached as a
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 and 20mm, 25mm and 30mm
Prostheses List by Category, Groups and Sponsor Page 10 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
W L Gore & Associates
GT223 Helex 1.5 Septal Occluder The GORE HELEX Septal Occluder Diameters: 15, 20, 25, 30 and $10,200.00
consists of an implantable endoprosthesis 35mm
and a catheter delivery system. The
Occluder is comprised of a nickel-
titanium (Nitinol) wire frame covered
with expanded polytetrafluoroethylene
(ePTFE). The ePTFE is treated with
Sub-Group 3: Vascular Occlusion Devices
Denward Dell Pty Ltd TA Surimex
DW001 Nit-Occlud PDA Occlusion System Nitinol spiral coil and delivery system for Distal x Proximal Coil Diameter: $1,900.00
transcatheter occlusion of PDA 4x4mm, 5x4mm, 6x5mm,
10x6mm, 12x6mm, 14x6mm;
Introducer Sheath: 4F, 5F;
Length Introducer: 85cm,
105cm; Coil Length
configurated +-0.5mm: 3.5mm,
DW002 Nit-Occlud PDA Occlusion System Nitinol spiral coil and delivery system for Distal x Proximal Coil Diameter: $1,650.00
(Medium) transcatheter occlusion of PDA 7 x 6mm, 9 x 6mm, 11 x 6mm,
12 x 6mm, 14 x 6mm;
Introducer Sheath: 5F; Length
Introducer: 85cm, 105cm; Coil
Length configurated +-0.5mm:
Group 14: Implantable Cardiac Event Recorders
Medtronic Australasia Pty Ltd
MC763 Reveal XT Reveal XT Insertable Cardiac Monitor 61 x 19 x 8 mm with a volume $3,900.00
of 9cc
MC768 Reveal DX Insertable Cardiac Monitor 61 x 19 x 8 mm with a volume $3,900.00
of 9cc
St. Jude Medical Australia Pty Ltd
SJ152 SJM Confirm Model DM2102 Implantable cardiac monitor with atrial 6.5cc, 12g $3,900.00 Temporary Listing
fibrillation monitoring.
SJ159 SJM Confirm Model DM2100 Implantable cardiac monitor 6.5cc, 12g $3,900.00 Temporary Listing
Prostheses List by Category, Groups and Sponsor Page 11 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 15: Endovascular Therapeutic Devices
Sub- Group 2: Embolic Protection Devices
St. Jude Medical Australia Pty Ltd
SJ127 Proxis Embolic Protection System - Proximal embolic protection device and 6F and 7F $2,100.00
Long Sheath delivery system
Group 2 - Cardiothoracic Tissue Valves
Edwards Lifesciences Pty Ltd
EL032 Baxter Edwards Prima Plus Stentless Edwards Prima Plus. Porcine Valve; 19mm-29mm $4,841.00
Bioprosthesis Model 2500P Prosthetic Woven Polyester Cloth.
Heart Valve
Group 2a - Stented
Medtronic Australasia Pty Ltd
MC950 Mosaic Ultra Cinch II Small Aortic Root Bioprosthesis 19mm - 29mm $4,445.00 $5,650.00
MC962 Mosaic Cinch II Aortic Bioprosthesis 19mm -29mm $4,445.00 $5,345.00
St. Jude Medical Australia Pty Ltd
SJ141 SJM Epic Supra Valve triple composite Bioprosthetic heart valve Tissue Annulus Diameter - 19- $4,445.00
for supra-annular placement in the aortic 23mm
Total Height - 14-16mm
SJ156 SJM Epic Valve Triple composite bioprosthetic heart valve Aortic valve 21-29mm tissue $4,445.00
annulus diameter
14-20 total height
Mitral Valves 25-33mm tissue
annulus diameter
15-20mm total height
Prostheses List by Category, Groups and Sponsor Page 12 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
(p)
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-
SJ136 SJM Biocor Heart Valve Stented Porcine tissue valve Aortic Valves - Tissue Annulus $4,445.00
Diameter - 21 - 29mm
Mitral Valves -
Tissue Annulus Diameter - 25-
35mm
SJ192 Epic Flexfit Triple-composite Bioprosthetic heart Aortic Valves 21-29mm tissue $4,445.00
annulus diameter, 14-20mm total
height. Mitral Valves 25-33mm
tissue annulus diameter, 15-
20mm total height.
SJ201 Epic FlexFit Supra Triple-composite Bioprosthetic heart Tissue Annulus Diameter - $4,445.00
valve for supra-annular placement in the 19mm-23mm. Total Height
aortic position
B (Bovine), E (Equine), P (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
MC771 Mosaic Ultra Small Aortic Root Bioprosthesis 19mm-29mm $4,445.00 $5,650.00
Group 2b - Stented, pericardial
Edwards Lifesciences Pty Ltd
EL056 Magna Mitral Carpentier-Edwards PERIMOUNT 25, 27, 29, 31 and 33mm $5,000.00 $5,690.00
Magna Mitral Bioprosthesis, Model
Sorin Group
SA130 Mitroflow Pericardial Bioprosthesis 19-27mm $5,000.00
Prostheses List by Category, Groups and Sponsor Page 13 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
(p) Pericardial
Edwards Lifesciences Pty Ltd
EL058 Magna Ease Carpentier - Edwards PERIMOUNT 19, 21, 23, 25, 27 and 29mm $5,000.00 $6,100.00
Magna Ease Bioprosthesis, Model
B (Bovine), E (Equine), P (Porcine)
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
Group 2c - Non-Stented
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
e
Advanced Biomedical Pty Ltd
AB070 ATS 3f Aortic Bioprosthesis (EQUINE) Model 1000 - EQUINE Pericardium 19 - 29 mm $5,000.00
Bioprostheseis (non stented)
Prostheses List by Category, Groups and Sponsor Page 14 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 2: Dual Chamber ICD's
Generation 3
Guidant Australia Pty Ltd
GU149 Vitality 2 DR - Model T165 Dual Chamber ICD 30cc; 82g $43,680.00
GU150 Vitality 2 EL DR - Model T167 Dual Chamber ICD 30cc; 82g $43,680.00
Sorin Group
SA140 OVATIO DR 6550 Titanium dual chamber ICD, 29 cc 29cc $43,680.00
a
Boston Scientific Australia Pty Ltd
BS128 Confient RF HE Dual chamber ICD, high energy with RF 44cc, 87.5g $45,760.00
Sorin Group
SA147 Paradym DR 8550 Dual Chamber, High Energy, Implantable Weight: 90 grams; Volume: $45,760.00
Cardioverter Defibrillator with rate 32.6cc; Dimensions: 58.4 x 73.4
St. Jude Medical Australia Pty Ltd
SJ115 Atlas II+ DR V-268 Dual Chamber Cardioverter Defibrillator 39cc, 78g $45,760.00
SJ123 Current DR 2107 Dual Chamber Cardio-verter Defibrillator 39cc 78g $45,760.00
A,C,D
Medtronic Australasia Pty Ltd
MC721 Virtuoso DR ModelImplantable Cardioverter 37cc, 68g $45,760.00
Defibrillator, Dual Chamber
MC938 Virtuoso II DR Model - Implantable Cardioverter 37cc, 68g $45,760.00
Defibrillator, Dual Chamber
A,D
Biotronik Australia Pty Ltd
BT086 Lumax 340 DR-T ICD-DR 34 J with bidirectional Home One Size Only $45,760.00 $48,760.00
Monitoring. Dual chamber
BT101 Lumax 540 DR-T High Energy, Dual-Chamber ICD Diamensions: 66*55*13mm, $45,760.00 $48,760.00
(Implantable Cardiac Defibrillator) with Volume/Weight: 37.2cc/92g
Advanced Patient Management Via unique
Home Monitoring Technology
incorporating Automatic Ventricular
Prostheses List by Category, Groups and Sponsor Page 15 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Boston Scientific Australia Pty Ltd
BS135 Teligen 100 DR DF-1/IS-1 Dual chamber ICD, high energy with RF 31.5cc, 9.9mm $45,760.00
St. Jude Medical Australia Pty Ltd
SJ120 Current DR RF 2207 Dual Chamber Cardioverter Defibrillator 80g, 42cc $45,760.00
with RF Telemetry
SJ144 AnalyST DR Model CD2217-36 Dual Chamber cardioverter defibrillator 80g, 42cm $45,760.00 $47,760.00
with RF telemetry and ST Segment
A,D,E
Boston Scientific Australia Pty Ltd
BS134 TELIGEN 100 HE DR 4-SITE Dual Chamber ICD, high energy with RF 31.55cc, 9.9mm $46,510.00
c
Guidant Australia Pty Ltd
GU157 Vitality AVT - Model A155 Dual Chamber ICD with atrial therapies 30cc $43,680.00
D
Biotronik Australia Pty Ltd
BT091 Lumax 300 DR-T ICD-DR with bidirectional Home One size only $43,680.00 $46,680.00
St. Jude Medical Australia Pty Ltd
SJ215 AnalyST DR CD2217-30 Dual chamber cardioverter defribillator 74g, 38cc $43,680.00 $45,680.00
with RF telemetry and ST segment
Generation 4
a, d, e
St. Jude Medical Australia Pty Ltd
SJ235 AnalyST Accel DR CD2219-36Q Dual chamber cardioverter defibrillator 80g, 41cc $47,880.00
with RF telemetry and ST segment
monitoring and SJ4 connector
SJ239 Current Accel DR CD2215-36Q Dual Chamber Cardioverter Defibrillator 80g, 41cc $47,880.00
with RF Telemetry and SJ4 connector
A,C,D
Medtronic Australasia Pty Ltd
MC814 Secura DR Fully Automatic, Wireless Implantable 37cc $47,130.00
cardioverter defibrillator with high energy
capability and therapies for ventricular
and atrial tachyarrhythmia
Prostheses List by Category, Groups and Sponsor Page 16 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
A,D
St. Jude Medical Australia Pty Ltd
SJ143 AnalyST Accel DR CD2219-36 Dual Chamber cardioverter defibrillator 80g, 42cc $47,130.00 $48,480.00
with RF telemetry and ST Segment
SJ153 Current Accel DR RF CD2215-36 Dual Chamber Cardioverter Defibrillator 80g, 42cc $47,130.00 $48,480.00
with RF Telemetry
D
St. Jude Medical Australia Pty Ltd
SJ214 Current Accel DR RF CD2215-30 Dual chamber cardioverter defribillator 74g, 38cc $46,030.00
with RF telemetry
SJ217 AnalyST Accel DR CD2219-30 Dual Chamber cardioverter defibrillator 74g, 38cc $46,030.00
with RF telemetry and ST segment
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
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
Sorin Group
SA128 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
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
Prostheses List by Category, Groups and Sponsor Page 17 of 866
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 3: ICD's with CRT
Generation 2
Boston Scientific Australia Pty Ltd
BS129 LIVIAN CRT-D CRT-D with RF 40cc, 79.5g, 14.5mm $45,760.00
Guidant Australia Pty Ltd
GU147 Contak Renewal 4 CRT-D Model H190, CRT-D One Size only $45,760.00
Model H195
Sorin Group
SA138 OVATIO CRT-D 6750 Titanium, dual chamber ICD with CRT 30cc $45,760.00
a
Boston Scientific Australia Pty Ltd
BS130 LIVIAN CRT-D HE CRT-D, high energy with RF 44cc, 87.5g, 14.5mm $47,840.00
Guidant Australia Pty Ltd
GU144 Contak Renewal 4 HE CRT-D Model CRT-D high energy One size only $47,840.00
H197, Model H199
Sorin Group
SA145 PARADYM CRT-D 8750 Implantable Cardioverter Defibrillator 34cc, 94 grams; 61.8 x 73.4 x $47,840.00
with Cardiac Resynchronisation therapy, 11mm
High Energy
St. Jude Medical Australia Pty Ltd
SJ109 Atlas II+ HF V-367 Cardiac Resynchronisation Therapy 41cc, 79g $47,840.00
Defibrillator with V-V Timing
Programmability
SJ117 Promote CRT-D 3107 Cardiac Resynchronisation Therapy 41cc, 80g $47,840.00
Defibrillator
Prostheses List by Category, Groups and Sponsor Page 18 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
A,C
Guidant Australia Pty Ltd
GU155 Contak Renewal 4 AVT HE CRT - D - Implantable Cardioverter Defibrillator 40cc; 89g $47,840.00
Model M177, M179 with cardiac resynchronisation Therapy
A,C,D
Medtronic Australasia Pty Ltd
MC720 Concerto CRT-D Implantable Cardioverter Defibrillator 38cc $47,840.00 $50,000.00
with Cardiac Resynchronisation Therapy
MC937 Concerto II Fully automatic, wireless implantable 38cc $50,000.00
cardioverter defibrillator with Cardiac
Resynchronisation Therapy (CRT), and
therapies for ventricular and atrial
tachyarrhythmia.
A,D
Biotronik Australia Pty Ltd
BT089 Lumax 340 HF-T CRT-D 34 J with bidirectional Home One Size Only $47,840.00 $53,000.00
Monitoring
BT102 Lumax 540 HF-T High Energy, Three Chamber ICD Diamensions: 66*59*13 mm, $47,840.00 $53,000.00
(Implantable Cardiac Defibrillator) with Volume/Weight: 39.8cc/94g
Advanced Patient Management Via unique
Home Monitoring Technology
incorporating Automatic RV/LV
Threshold Monitoring and Extended
Boston Scientific Australia Pty Ltd
BS139 COGNIS 100 HE (DF-1/IS-1 & DF- CRT-D high energy with RF 32.5cc, 9.9mm $47,840.00
St. Jude Medical Australia Pty Ltd
SJ128 Promote RF CRT-D 3213 Cardiac Resynchronisation Therapy 43cc, 82g $47,840.00 $49,840.00
Defibrillator with RF Telemetry
A,D,E
Boston Scientific Australia Pty Ltd
BS138 COGNIS 100 HE 4-SITE CRT-D high energy with RF IS4 32cc, 9.9mm $48,590.00
c
Guidant Australia Pty Ltd
GU154 Contak Renewal 4 AVT CRT -D - Implantable Cardioverter Defibrillator 37cc; 89g $45,760.00
Model M170 and M175 with Cardiac Resynchronisation Therapy
Prostheses List by Category, Groups and Sponsor Page 19 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
D
Biotronik Australia Pty Ltd
BT088 Lumax 300 HF-T CRT-D with bidirectional Home One size only $45,760.00 $48,760.00
Generation 3
a, d, e
St. Jude Medical Australia Pty Ltd
SJ236 Promote Accel CD3215-36Q Cardiac Resynchronisation Therapy 82g, 43cc $52,750.00
Defibrillator with RF Telemetry and SJ4
connector
A,C,D
Medtronic Australasia Pty Ltd
MC812 Consulta CRT-D Fully Automatic, Wireless Implantable 38cc $52,000.00
cardioverter defibrillator with cardiac
resynchronization therapy (CRT), and
therapies for ventricular and atrial
tachyarrhythmia
A,D
St. Jude Medical Australia Pty Ltd
SJ150 Promote Accel RF CD3215-36 Cardiac Resynchronisation Therapy 82g, 43cc $52,000.00
Defibrillator with RF Telemetry
D
St. Jude Medical Australia Pty Ltd
SJ145 Promote Accel CD3215-30 Cardiac Resyncronisation Therapy 76g, 39cc $49,760.00
Defibrillator with RF Telemetry
Prostheses List by Category, Groups and Sponsor Page 20 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
Sorin Group
SA127 AnnuloFlo Annuloplasty System Annuloflex Ring or AnnuloFlo Ring 26-36mm $2,200.00
St. Jude Medical Australia Pty Ltd
SJ035 SJM Tailor Annuloplasty Ring Fully Flexible 25mm - 35mm $2,200.00
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
EL057 Geoform Geoform annuloplasty ring Model 4200 26, 28, 30 and 32mm $2,400.00
with Holder
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
MC844 Profile 3D Annuloplasty Ring 3D, rigid annuloplasty ring with Diameter (mm) 24 - 40mm $2,400.00
physiologic mitral valve shape
Prostheses List by Category, Groups and Sponsor Page 21 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
St. Jude Medical Australia Pty Ltd
SJ087 St Jude Medical Rigid Saddle Ring Rigid Annuloplasty Ring 24 - 34mm $2,400.00
SJ195 Attune Flexible Adjustable Annuloplasty Flexible annuloplasty ring 25mm - 43mm $2,200.00
Ring
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
Reid Healthcare
RH002 Kalangos Mitral Ring KALANGOS Mitral Ring is intended for Diameter 16mm - 36mm, Height $2,200.00 $2,500.00
heart valve repair. Each device is 10.62mm - 24.61mm
characterized by a resorbable polymeric Thickness 1.3mm - 1.5mm
curved segment, processed in poly-1,4-
dioxanone, moulded around a PVDF
suture itself ended by swaged stainless
steel needles. These three constituents are
assembled in such a way that they
cannot be shared or dismounted after
assembly without irremediably destroying
the device. For these reasons,
KALANGOS Mitral Ring should be
considered as a single device. Each
extremity of the polymeric segment is
terminated by a sharp end prolonged by
the PVDF suture with a swaged stainless
Prostheses List by Category, Groups and Sponsor Page 22 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
RH003 Kalangos Tricuspid Ring KALANGOS Tricuspid Ring is intended TRK16 5.10 Radius 1 (mm) $2,200.00 $2,500.00
for heart valve repair. Each device is 9.31 Radius 2 (mm) 3.1 Radius
characterized by a resorbable polymeric 3 (mm) 5.44 Height (mm) 1.30
curved segment, processed in poly-1,4- Thickness (mm)
dioxanone, moulded around a PVDF TRK18 6.1 Radius 1 (mm)
suture itself ended by swaged stainless 10.44 Radius 2 (mm) 4.1 Radius
steel needles. These three constituents are 3 (mm) 7.98 Height (mm) 1.30
assembled in such a way that they Thickness (mm)
cannot be shared or dismounted after TRK20 7.1 Radius 1 (mm) 8.92
assembly without irremediably destroying Radius 2 (mm) 5.1 Radius 3
the device. For these reasons, (mm) 8.96 Height (mm) 1.30
KALANGOS Tricuspid Ring should be Thickness (mm)
considered as a single device. Each TRK22 8.1 Radius 1 (mm) 9.27
extremity of the polymeric segment is Radius 2 (mm) 6.1 Radius 3
terminated by a sharp end prolonged by (mm) 10.05 Height (mm) 1.30
the PVDF suture with a swaged stainless Thickness (mm)
steel needle on both sides. TRK24 9.1 Radius 1 (mm)
11.21 Radius 2 (mm) 7.1 Radius
3 (mm) 10.97 Height (mm)
1.30 Thickness (mm)
TRK26 10 Radius 1 (mm) 11.21
Radius 2 (mm) 8 Radius 3
(mm) 10.37 Height (mm) 1.50
Thickness (mm)
TRK28 10.5 Radius 1 (mm)
16.71 Radius 2 (mm) 9 Radius 3
(mm) 11.02 Height (mm) 1.50
Thickness (mm)
TRK30 12 Radius 1 (mm) 11.9
Radius 2 (mm) 10 Radius 3
(mm) 12.83 Height (mm) 1.50
Thickness (mm)
TRK32 13 Radius 1 (mm) 15.45
Radius 2 (mm) 11 Radius 3
(mm) 13.15 Height (mm) 1.50
Thickness (mm)
TRK34 14 Radius 1 (mm) 16.25
Radius 2 (mm) 12 Radius 3
(mm) 13.5 Height (mm) 1.50
Thickness (mm)
TRK36 15 Radius 1 (mm) 15.85
Radius 2 (mm) 13 Radius 3
(mm) 16.09 Height (mm) 1.50
Thickness (mm)
Prostheses List by Category, Groups and Sponsor Page 23 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
St. Jude Medical Australia Pty Ltd
SJ088 SJM Tailor Annuloplasty Band Flexible double-velour, polyester fabric 25 - 35mm $2,200.00
Group 4: 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
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 $5,928.00
BT106 Cylos 990 SR Single-chamber pacemaker with Closed 57 x 39 x 6mm / 27g $5,928.00
Loop Stimulation (CLS)
BT109 Entovis SR Fully automatic, extended longevity, 53 x 39 x 6.5W x H x D [mm], $5,928.00
single cFully automatic, extended Size 1 [cm3], 25 Mass[g]
longevity, single chamber pacemaker with
Closed Loop Stimulation.
BT113 Evia SR Fully automatic, extended longevity, 53 x 39 x 6.5 W x H x D [mm], $5,928.00
single chamber pacemaker with Closed Size 10[cm3], 25 Mass [g]
Loop Stimulation.
Boston Scientific Australia Pty Ltd
BS124 Insignia AVT 1192 Single chamber rate responsive 10cc, 23.4g $5,928.00
BS145 Altrua 20 SR Single chamber rate responsive 10cc - 15cc $5,928.00
BS147 Altrua 40 SR Single chamber rate responsive 10cc - 15cc $5,928.00
Prostheses List by Category, Groups and Sponsor Page 24 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
BS149 Altrua 50 SR Single chamber rate responsive 10cc - 15cc $5,928.00
BS152 Altrua 60 SR Single chamber rate responsive 10cc - 15cc $5,928.00
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 Model 1190 Single Chamber Rate Responsive One size only $5,928.00
Medtronic Australasia Pty Ltd
MC728 Adapta Pacemaker SR PacemakerModels ADSR01, 9.7 - 11.0cc21.5 - 22.5g $5,928.00
ADSR06, ADSR03
Sorin Group
SA137 Symphony SR Titanium one size only $5,928.00
SA142 Reply™ SR Single chamber permenent pacemaker 37 x 41.5 x 6.1mm $5,928.00
with rate response modulation 19 Grams
7.5 cm3
SA143 ESPRIT SR Single Chamber Permanent Pacemaker Dimensions: 37.4 x 41.5 x $5,928.00
with Rate Response Modulation 6.1mm Weight : 19grams.
St. Jude Medical Australia Pty Ltd
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
SJ131 Zephyr XL SR 5626 Single-Chamber Rate-Responsive 23.5g and 10.4cc $5,928.00
SJ205 Accent SR PM 1110 Single Chamber Rate Responsive 18g, 9.5cc $5,928.00
a
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
Prostheses List by Category, Groups and Sponsor Page 25 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
D
Biotronik Australia Pty Ltd
BT108 Entovis SR-T Fully automatic, extended longevity, 53 x 39 x 6.5 W x H x D [mm], $5,928.00 $8,928.00
single chamber pacemaker with Closed Size 11 [cm3], 24 mass[g]
Loop Stimulation & BIOTRONIK Home
Monitoring
BT110 Evia SR-T Fully automatic, extended longevity, 53 x 39 x 6.5 W x H x D [mm], $5,928.00 $8,928.00
single chamber pacemaker with Closed Size 11 [cm3], 24 Mass [g]
Loop Stimulation & BIOTRONIK Home
Monitoring
St. Jude Medical Australia Pty Ltd
SJ200 Accent SR RF PM1210 Single Chamber Pacemaker with RF 23g, 12.8cc $5,928.00 $7,928.00
Group 5 - Cardiothoracic Membranes and Patches
Group 5a - Tissue
Advanced Biomedical Pty Ltd
AB066 Supple Peri-Guard (10 x 16cm) Model No PC1016SN - 10 x 16 Bovine 10 x 16cm $760.00
pericardium patch
AB067 Supple Peri-Guard (8 x 14cm) Nodel No PC0814SN - 8 x 14 Bovine 8 x 14cm $700.00
pericardium patch
AB068 Supple Peri-Guard (6 x 8cm) Model No PC0608SN -6 x 8cm Bovine 6 x 8cm $610.00
pericardium patch
AB069 Supple Peri-Guard (4 x 4cm) Model No PC0404SN - 4 x 4cm Bovine 4 x 4cm $350.00
pericardium patch
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
Tag Medical
TM040 Repel - CV Bioresorbable Adhesion Barrier 18cmx13.5cmx137 microns $550.00
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 26 of 866
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 5: Dual Chamber Pacemakers
Generation 1
Boston Scientific Australia Pty Ltd
BS123 Insignia AVT 882 Dual chamber VDD pacemaker 10.0cc, 23.5g $5,200.00
BS150 Altrua 50 VDD Dual chamber VDD pacemaker 10cc - 15cc $5,200.00
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 PacemakerModels ADVDD01 11.1cc23.6g $6,760.00
Prostheses List by Category, Groups and Sponsor Page 27 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
BT060 Philos II DR Multiprogrammable, rate responsive, One size only $9,360.00
BT104 Cylos 990 DR Dual-chamber pacemaker with Closed 57* 43* 6mm/28g $9,360.00
Loop Stimulation (CLS)
BT105 Cylos 990 DR-T Dual-chamber pacemaker with Closed 57*43*6mm/28g $9,360.00 $12,360.00
Loop Stimulation (CLS) and Biotronik
Home Monitoring Technology
Boston Scientific Australia Pty Ltd
BS126 Insignia AVT 1292 Dual chamber rate responsive pacemaker 10.8cc, 25.4g $9,360.00
BS144 Altrua 20 DR Dual chamber rate responsive pacemaker 10cc - 15cc $9,360.00
BS146 Altrua 40 DR Dual chamber rate responsive pacemaker 10cc - 15cc $9,360.00
BS148 Altrua 50 DR Dual chamber rate responsive pacemaker 10cc - 15cc $9,360.00
BS151 Altrua 60 DR Dual chamber rate responsive pacemaker 10cc - 15cc $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 Dual Chamber Rate Responsive One size only $9,360.00
GU141 Insignia Ultra DR Model 1290 Dual Chamber Rate Responsive One size only $9,360.00
Sorin Group
SA136 Symphony DR 2550 Active Implantable pacemaker 1 size only $9,360.00
SA141 Reply™ DR Dual Chamber permanent Pacemaker 8cc, Weight: 20grams, $9,360.00
with Rate Response Modulation Dimensions:41.2 x 41.5 x
Prostheses List by Category, Groups and Sponsor Page 28 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
SA144 ESPRIT DR Dual Chamber Permanent Pacemaker 8cc, Weight: 20grams, $9,360.00
with Rate Response Modulation Dimensions:41.2 x 41.5 x
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
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 8ccADx XL DR
5386: 44x52x6mm, 23.5g and
SJ089 Victory XL DR 5816 and DR 5810 Dual Chamber Rate Responsive 44x52x6mm; 23.5g; 11cc $9,360.00
b
Medtronic Australasia Pty Ltd
MC360 EnRhythm Model P150 1DR, Rate Responsive dual 21g, 13cc $11,440.00
chamber pacemaker with Anti-
Tachycardia functions: DDDRP
MC935 EnRhythm MRI SureScan Model EMDR01, MRI Conditional, Rate 13cc, 22g $11,440.00
Responsive Dual Chamber Pacemaker
with Anti-Tachycardia functions and
D
Biotronik Australia Pty Ltd
BT071 Philos II DR-T Dual Chamber Rate Responsive with One size only $9,360.00 $12,360.00
Home Monitoring
BT079 Cylos DR-T Dual chamber dual sensor rate responsive one size $9,360.00 $12,360.00
with home monitoring system option
Generation 4
Biotronik Australia Pty Ltd
BT111 Entovis DR Fully automatic, extended longevity, Dual 53 x 43 x 6.5W x H x D [mm], $11,440.00
Chamber Pacemaker with Closed Loop Size 11 [cm3], 26 Mass [g]
stimulation & Vp Suppression
BT112 Evia DR Fully automatic, extended longevity, Dual 53 x 43 x 6.5 W x H x D [mm], $11,440.00
Chamber Pacemaker with Closed Loop Size 11 [cm3], 26 Mass [g]
stimulation & Vp Suppression.
Medtronic Australasia Pty Ltd
MC726 Adapta Pacemaker DR PacemakerModels ADDR01, 11.1-14.2cc23.6g-31.3g $11,440.00
ADDRS1, ADDRL1, ADDR06, ADDR03
Prostheses List by Category, Groups and Sponsor Page 29 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
SJ193 Accent DR PM 2112 Dual Chamber Pacemaker 19g, 10.5cc $11,440.00
b
Medtronic Australasia Pty Ltd
MC933 Advisa DR MRI SureScan Model A3DR01 Digital dual chamber 13cc, 22g $11,780.00
pacemaker with SureScan Technology
(OAE-DDDR) MR Conditional with MVP
Mode, Complete Capture Management
Diagnostic (ACM, RVCM), AT/AF Suite
Diagnostics and Therapies, OptiVol Fluid
Status Monitoring, and Therapy Guide
MC934 Advisa DR Model A5DR01 Digital dual chamber 13cc, 22g $11,780.00
pacemaker (OAE-DDDR) MVP mode
with Complete Capture Management
Diagnostic (ACM, RVCM) AT/AF Suite
Diagnostics and Therapies, OptiVol Fluid
Status Monitoring, and Therapy Guide
D
Biotronik Australia Pty Ltd
BT114 Evia DR-T Fully automatic, extended longevity, Dual 53 x 44.5 x 6.5 W x H x D $11,440.00 $14,440.00
Chamber Pacemaker with Closed Loop [mm], Size 12 [cm3], 25 Mass
stimulation, Vp Suppression and
BIOTRONIK Home Monitoring
BT115 Entovis DR-T Fully automatic, extended longevity, Dual 53 x 44.5 x 6.5 W x H x D $11,440.00 $14,440.00
Chamber Pacemaker with Closed Loop [mm], Size 12 [cm3], 25 Mass
stimulation, Vp Suppression and
BIOTRONIK Home Monitoring
St. Jude Medical Australia Pty Ltd
SJ196 Accent DR RF PM2212 Dual chamber Pacemaker with RF 236, 12.8cc $11,440.00 $13,440.00
Group 6 - Cardiothoracic Assisted Anastomic Devices
Medtronic Australasia Pty Ltd
MC680 Spyder Proximal Anastomotic Device 6-clip assembly $590.00
Prostheses List by Category, Groups and Sponsor Page 30 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 6: CRT Pacemakers
Generation 2
Guidant Australia Pty Ltd
GU142 Contak Renewal TR2 CRT - P Model CRT-P 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
D
Biotronik Australia Pty Ltd
BT085 Stratos LV-T Multiprogrammable Biventricular DDDRV One size only $12,480.00 $15,480.00
with Home Monitoring
Generation 3
St. Jude Medical Australia Pty Ltd
SJ194 Anthem PM3112 CRT Pacemaker Cardiac Resynchronisation Therapy 21g, 11.5cc $13,520.00 $14,560.00
Pacemaker
D
St. Jude Medical Australia Pty Ltd
SJ207 Anthem RF PM3212 CRT Pacemaker with RF telemetry 25g, 13.7cc $13,520.00 $14,560.00
Group 7 - Cardiothoracic Assisted Fixation Devices
Group 7a Valvular
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 31 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 7b Related to anastomosis
Medtronic Australasia Pty Ltd
MC765 U-Clips Nitinol Clips, 8-pack Needle Lengths: 6.5mm - $336.00
9.5mm, 8-pack
MC772 U-Clips Nitinol Clips, 2-pack Needle Lengths: 6.5mm - $84.00
9.5mm, 2-Pack
Group 7c Related to skeletal fixation
s
Advanced Biomedical Pty Ltd
AB074 FLEXIGRIP (Various Sizes) Nitinol Sternal Closure Clips - various sizes 20mm - 40mm $80.00 $160.00
Group 7: ICD Leads
Sub -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;
Sub -Group 2: Subcutaneous Leads
Guidant Australia Pty Ltd
GU123 Endotak SQ Array XP Lead Model 0085 Sub-Q Array for high DFT 70cm $4,680.00
Medtronic Australasia Pty Ltd
MC251 Implantable Subcutaneous Defibrillator Silicone and Platinum Alloy Lengths 41-85cm inclusive $4,680.00
Lead Model 6996SQ 41cm, 58cm,
Sub -Group 5: Transvenous/ Steroid/ Passive Leads
Biotronik Australia Pty Ltd
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
Prostheses List by Category, Groups and Sponsor Page 32 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
BT119 Linox SMART TD Linox SMART TD is a family of ICD Length: Linox SMART TD $9,360.00
leads with an active fixation helix. The 65/16 65cm, Linox SMART TD
fixation helix is comprised of platinum 65/18 65cm, Linox SMART TD
75/18 75cm; Lead Body
Guidant Australia Pty Ltd
GU115 Endotak Reliance Lead Passive Dual Coil 59cm, 64cm, 90cm $9,360.00
GU158 Endotak Reliance SG Passive Passive Single Coil wih GORE ePTFE 54cm - 90cm $9,360.00
covered coils
GU159 Endotak Reliance G Passive Passive Dual Coil with GORE ePTFE 54cm - 90cm $9,360.00
covered coils
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
Sorin Group
SA148 ISOLINE 2CT Passive fixation, steroid eluting, Lead body is 7.8 French $9,360.00
intergrated bipolar, dual shock coil diameter whilst 65cm in length
St. Jude Medical Australia Pty Ltd
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
SJ130 Riata ST Optim 7070/1 Passive Fixation, True bipolar, Dual Coil, 60, 65 and 70cm length, 7Fr $9,360.00
Steroid Eluting, Endocardial Defibrillation introducer
Leads with Optim insulation overlay
SJ158 Durata 7170, 7171 Passive fixation, true bipolar, dual coil, 60, 65 and 70cm $9,360.00
steroid eluting, endocardial defibrillation
leads with Optium insulation overlay
a
Boston Scientific Australia Pty Ltd
BS170 Endotak Reliance S 4-SITE Passive fixation single coil defibrillation 50-70cm $9,360.00
leads & 4-SITE connector.
Prostheses List by Category, Groups and Sponsor Page 33 of 866
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
BS180 Endotak Reliance G 4-SITE Passive fixation dual coil defibrillation 50-70cm $9,360.00
leads with ePTFE covered coils & 4-
1. The external indwelling surface of Quad Lumen
catheter material (chorhexidine and silver
sulphadiazine)
2. The entire internal fluid pathway
including catheter, extension-lines and
hubs (chlorhexidine acetate)
CM020 ARROWg+ard Blue Plus Double & Double & Triple Lumen Central Venous CS-45802E - 8 Fr x 20cm, Dual $120.00
Triple Lumen Central Venous Catheters Catheters (of various lengths sizes and Lumen
lumen configurations) with antimicrobial CS-46702E - 7Fr x 20cm, Dual
impregnation on: Lumen
1. The external indwelling surface of CS-47702E - 7Fr x 20cm, Dual
catheter material (chlorhexidine and silver Lumen
sulphadiazine) CS-42703E - 7Fr x 16cm, Triple
2. The entire internal fluid pathway Lumen
including catheter, extension-lines and CS-45703E - 7Fr x 20cm, Triple
hubs (chlorhexidine acetate) Lumen
Prostheses List by Category, Groups and Sponsor Page 863 of 866
VASCULAR CAG
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
pi
Bard Australia Pty Ltd
BA182 PowerPICC Triple Lumen Power Injector Catheter 6F, 55cm length $230.00
BA183 PowerPICC Dual Lumen Power Injector Catheters 5F, 6F, 55cm Length $225.00
Mayo group
CM021 Arrow double lumen pressure injectable Arrow double lumen pressure injectable 5Fr x 50cm, Double Lumen $225.00
peripherally inserted central catheter PICC (peripherally inserted central
(PICC) set
Group 9c: Infuser Ports – single chamber
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 Titanium or MRI Implantable Port, Open- 6FR - 9.6Fr $500.00
Ended Catheter Sinlgle Chamber
BA057 Groshong Subcutaneous Ports Titanium or MRI Implatable Port, Closed- 7Fr - 8 Fr $521.00
Ended Catheter, Single Chamber
BA060 Subcutaneous Ports Low-Profile Titanium or MRI Implantable 6 - 6.6 French Catheter $534.00 $653.00
Port, Open-Ended Catheter Sinlgle
BMDi Tuta Healthcare Pty Ltd
TT001 Paragon Ambulatory Drug Infusion The top of the Paragon infuser is made of Infuser - 100mL Administration $534.00
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
Cook Medical 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
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
Prostheses List by Category, Groups and Sponsor Page 864 of 866
VASCULAR CAG
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
WC115 Cook Implantable Injection/Infusion Mini, single or multiple chamber titanium 3 - 12 Fr pre-attached or $534.00 $652.00
Port which may include micropuncture detached catheter or valve system
introducer set
Denward Dell Pty Ltd TA Surimex
DW003 Jet Port Plus Set - Vascular Access Port Implantable injection / infusion port Port: Diameter: 28.0mm, $375.00
system: port chamber with silicone Height: 12.3mm; Catheter: 6.6
membrane; connectable polyurethane French, Length: 750mm
catheter; and introducer kit.
DW004 Jet Port Plus Low Profile Peripheral Set Implantable injection / infusion port Port: Length: 24.0mm, Width: $420.00
- Vascular Access Port system: low profile port chamber with 20.5mm, Height: 10.3mm
silicone membrane; connectable Catheter: 6.6 French, Length:
polyurethane catheter; and introducer kit 750mm
Medical Specialties Australia Pty Ltd
MS016 Injection/Infusion Ports Sterile Plastic/titanium, paediatric 5, 6, 7,8, 9.6F $771.00
ds
Medical Specialties Australia Pty Ltd
MS014 Injection/Infusion Ports Sterile Plastic/titanium, single lumen 5-15F $771.00
pi
Bard Australia Pty Ltd
BA181 PowerPort Sterile Titanium or MRI, subcutaneous One size, OF Catheter $630.00
implanted port with attachable radiopaque
open ended ChronoFlex polyurethane
catheter, intermediate kit
BA208 PowerPort with Groshong Catheter Titanium or MRI implantable Port, 8Fr $630.00 $750.00
Closed-Ended Catheter, Single Chamber
Prostheses List by Category, Groups and Sponsor Page 865 of 866
VASCULAR CAG
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Denward Dell Pty Ltd TA Surimex
DW006 T-Port Contrast set - Vascular access Injection infusion port system: titanium 6163653077: Port Base 27mm x $630.00
port chamber with silicone membrane: 13mm, Catheter Diameter 1.3 x
connectable polyurethane catheter; 2.2mm, Catheter Length 75cm.
introducer kit. 6163652087: Port Base 27mm x
13mm, Catheter Diameter 1.6 x
2.6mm, Catheter Length 75cm.
6163663077: Port Base 23mm x
10mm, Catheter Diameter 1.3 x
2.2mm, Catheter Length
75cm.6163662087: Port Base
23mm x 10mm, Catheter
Diameter 1.6 x 2.6mm, Catheter
Length 75cm.
Group 9d: Infuser Ports – multiple chambers
Bard Australia Pty Ltd
BA059 Dual Lumen Subcutaneous Ports Silicone, Polyurethane or ChronoFlex 7 - 10 French Catheter $805.00
Open-ended Catheter
Cook Medical 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
Denward Dell Pty Ltd TA Surimex
DW005 Dual Port Set - Vascular Access Port Implantable injection / infusion port Port: Length: 53.0mm, Width: $580.00
system: dual port chamber with silicone 20.0mm, Height: 13.5mm
membranes; connectable double lumen (chamber 1), 15.5mm (chamber
polyurethane catheter; and introducer kit. 2); Catheter: Length: 500mm,
internal diameter double D,
external diameter 3mm
Medical Specialties Australia Pty Ltd
MS015 Injection/Infusion Ports Sterile Plastic/titanium, dual lumen 10, 10.5, 12F $786.00
Grand Total: 9233 Records
Prostheses List by Category, Groups and Sponsor Page 866 of 866
PART B - Human Tissue List August 2010
CARDIO-THORACIC
Billing Code Facility Minimum Benefit Maximum Benefit
Conduit - Aortic
TBV56 Donor Tissue Bank of Victoria $1,013.00
Conduit - Aortic + Valve
QHV09 The Prince Charles Hospital - Queensland Heart Valve Bank $5,499.00
Conduit - Arterial
SHV03 Sydney Heart Valve Bank, St. Vincent's Hospital $987.00
Conduit - Pulmonary
TBV03 Donor Tissue Bank of Victoria $1,012.00
Conduit - Pulmonary + Valve
QHV08 The Prince Charles Hospital - Queensland Heart Valve Bank $5,499.00
Conduit - Pulmonary large
QHV07 The Prince Charles Hospital - Queensland Heart Valve Bank $1,448.00
Conduit - Pulmonary small
QHV06 The Prince Charles Hospital - Queensland Heart Valve Bank $1,448.00
Patch - Mitral
QHV03 The Prince Charles Hospital - Queensland Heart Valve Bank $1,448.00
Patch - Pericardium
QHV05 The Prince Charles Hospital - Queensland Heart Valve Bank $1,448.00
Patch - Tricuspid
QHV04 The Prince Charles Hospital - Queensland Heart Valve Bank $1,448.00
Pericardium
TBV50 Donor Tissue Bank of Victoria $490.00
Thoracic Aorta
QHV11 The Prince Charles Hospital - Queensland Heart Valve Bank $1,450.00
Valve - Aortic
QHV01 The Prince Charles Hospital - Queensland Heart Valve Bank $5,499.00
RPH01 Royal Perth Hospital T/A Heart Valve Bank $6,406.00
SHV01 Sydney Heart Valve Bank, St. Vincent's Hospital $5,350.00
Page 1 of 15
CARDIO-THORACIC
Billing Code Facility Minimum Benefit Maximum Benefit
TBV01 Donor Tissue Bank of Victoria $6,598.00
Valve - Mitral
QHV10 The Prince Charles Hospital - Queensland Heart Valve Bank $5,499.00
Valve - Pulmonary
QHV02 The Prince Charles Hospital - Queensland Heart Valve Bank $5,499.00
RPH02 Royal Perth Hospital T/A Heart Valve Bank $6,406.00
SHV02 Sydney Heart Valve Bank, St. Vincent's Hospital $5,350.00
TBV02 Donor Tissue Bank of Victoria $6,598.00
Amniotic Membrane
LEM03 Lions Eye Donation Service $770.00
Cornea
LEM01 Lions Eye Donation Service $2,000.00
LEN01 Lions NSW Eye Bank $1,633.00
LEW01 Lions Eye Bank of Western Australia $2,500.00
QEB01 Queensland Eye Bank $2,100.00
SAE01 The Eye Bank of South Australia $1,000.00
Cornea for Endothelial Lamellar Keratoplasty
LEM04 Lions Eye Donation Service $2,660.00
Cornea For Lamellar
LEN03 Lions NSW Eye Bank $980.00
Sclera
LEM02 Lions Eye Donation Service $150.00
LEN02 Lions NSW Eye Bank $245.00
LEW02 Lions Eye Bank of Western Australia $250.00
QEB02 Queensland Eye Bank $298.00
SAE02 The Eye Bank of South Australia $60.00
Autologous Chondrocyte Implant
MVS22 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $9,538.00
Autologous Chondrocytes Implant and Matrix
ORT01 Orthogen Australia Pty Ltd $11,400.00
VAP01 Verigen Australia Pty Ltd $11,400.00
Page 2 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
Autologous Skull Flap
MVS23 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $1,396.00
QBB60 The Queensland Bone Bank $1,568.00
RNB02 Hunter New England Bone Bank $1,470.00
Autologous Skull Flap - processed
QBB56 The Queensland Bone Bank $1,986.00
Bone - Cancellous Bone Matrix, Lyophilised 40cc
TBV52 Victorian Institute of Forensic Medicine $619.00
Bone - Cancellous Bone Matrix, Lyophilised 80cc
TBV53 Victorian Institute of Forensic Medicine $1,237.00
Bone - Cancellous Crunch 15cc
NBB62 New South Wales Bone Bank $903.00
Bone - Cancellous Crunch 30cc
NBB61 New South Wales Bone Bank $1,647.00
Bone - Cancellous Crunch 60cc
NBB60 New South Wales Bone Bank $2,498.00
Bone - Cancellous Cubes (6) Freeze Dried
QBB09 The Queensland Bone Bank $1,609.00
Bone - Cancellous Strips (2) Freeze Dried
QBB10 The Queensland Bone Bank $680.00
Bone - Chips/cubes 40cc
TBV09 Donor Tissue Bank of Victoria $973.00
Bone - Chips/cubes 80cc
TBV10 Donor Tissue Bank of Victoria $1,853.00
Bone - Cortico-Cancellous Crunch (40/60) 15cc
NBB65 New South Wales Bone Bank $903.00
Bone - Cortico-Cancellous Crunch (40/60) 30cc
NBB64 New South Wales Bone Bank $1,647.00
Bone - Cortico-Cancellous Crunch (40/60) 60cc
NBB63 New South Wales Bone Bank $2,498.00
Page 3 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
Bone – Cortico-Cancellous Crunch <20g Sterile
AUB08 Australian Biotechnologies $2,215.00
Bone – Cortico-Cancellous Crunch <30g
AUB04 Australian Biotechnologies $2,070.00
Bone - Demineralised Bone Matrix, Lyophilised 10g
TBV55 Donor Tissue Bank of Victoria $1,049.00
Bone - Demineralised Bone Matrix, Lyophilised 5g
TBV54 Donor Tissue Bank of Victoria $524.00
Bone - Milled <30g Freeze Dried
PBT37 Perth Bone and Tissue Bank $750.00
Bone - Milled <30gr (60cc equivalent)
PBT08 Perth Bone and Tissue Bank $2,070.00
Bone - Milled >50gr (100cc equivalent)
PBT10 Perth Bone and Tissue Bank $3,041.00
Bone - Milled 20g
QBB45 The Queensland Bone Bank $1,993.00
Bone - Milled 20g Freeze Dried
QBB03 The Queensland Bone Bank $2,524.00
Bone - Milled 30 - 50gr (60 - 100cc equivalent)
PBT09 Perth Bone and Tissue Bank $2,652.00
Bone - Milled 30-50g Freeze Dried
PBT38 Perth Bone and Tissue Bank $900.00
Bone - Milled 40cc
TBV11 Donor Tissue Bank of Victoria $1,165.00
Bone - Milled 80cc
TBV12 Donor Tissue Bank of Victoria $2,084.00
Bone - Milled Femoral Head
AUB02 Australian Biotechnologies $2,457.00
Bone - Ronguered Chips
QBB68 The Queensland Bone Bank $2,022.00
Page 4 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
Bone - Ronguered Chips Freeze Dried
QBB67 The Queensland Bone Bank $2,524.00
Bone Plug/Dowel - Cancellous
NBB05 New South Wales Bone Bank $1,224.00
PBT03 Perth Bone and Tissue Bank $500.00
TBV07 Donor Tissue Bank of Victoria $691.00
Bone Plug/Dowel - Tricortical
TBV08 Donor Tissue Bank of Victoria $750.00
Cartilage - costal segments
PBT11 Perth Bone and Tissue Bank $300.00
QBB12 The Queensland Bone Bank $210.00
TBV17 Donor Tissue Bank of Victoria $390.00
Cortical Strut
AUB05 Australian Biotechnologies $2,451.00
QBB52 The Queensland Bone Bank $441.00
TBV14 Donor Tissue Bank of Victoria $763.00
Cortical Strut >15 - 20cm
PBT07 Perth Bone and Tissue Bank $2,215.00
Cortical Strut >20cm
PBT48 Perth Bone and Tissue Bank $2,451.00
Cortical Struts 10-15cm
PBT06 Perth Bone and Tissue Bank $1,856.00
Disc - Freeze Dried
QBB04 The Queensland Bone Bank $713.00
Elbow - joint
QBB14 The Queensland Bone Bank $2,205.00
TBV18 Donor Tissue Bank of Victoria $5,247.00
Fascia Lata
NBB09 New South Wales Bone Bank $922.00
TBV21 Donor Tissue Bank of Victoria $806.00
Fascia Lata - Large (15cm x 10cm)
Page 5 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
PBT15 Perth Bone and Tissue Bank $1,539.00
Fascia Lata - per sq cm
QBB11 The Queensland Bone Bank $5.00
Fascia Lata - Small (10cm x 5cm)
PBT16 Perth Bone and Tissue Bank $800.00
Femoral Head
ACT01 ACT Bone Bank $2,113.00
APH01 The Avenue Private Hospital Bone Bank $1,131.00
AUB03 Australian Biotechnologies $2,354.00
CSA01 Rachel Forster Bone Bank $802.00
DHR01 Barwon Health Bone Bank $2,113.00
HBB01 The Hobart Private Hospital Bone Bank $2,113.00
LPH01 Lingard Private Hospital Bone Bank $1,103.00
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 $2,354.00
PBT22 Perth Bone and Tissue Bank $2,354.00
QBB27 The Queensland Bone Bank $2,163.00
RNB01 Hunter New England Bone Bank $1,870.00
SVN01 Mater Hospital $731.00
TBV26 Donor Tissue Bank of Victoria $2,354.00
Femoral Head - Autologous
QBB61 The Queensland Bone Bank $2,163.00
Femoral Head - Freeze Dried
QBB28 The Queensland Bone Bank $2,163.00
Femoral Hemi-condyle
NBB59 New South Wales Bone Bank $2,271.00
PBT21 Perth Bone and Tissue Bank $2,150.00
TBV46 Donor Tissue Bank of Victoria $1,206.00
Femoral Rings
NBB17 New South Wales Bone Bank $1,606.00
PBT24 Perth Bone and Tissue Bank $1,591.00
Page 6 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
QBB30 The Queensland Bone Bank $1,591.00
Femoral Rings - Freeze Dried
QBB31 The Queensland Bone Bank $670.00
Femoral Shaft
QBB23 The Queensland Bone Bank $2,247.00
Femoral Shaft - Freeze Dried
QBB66 The Queensland Bone Bank $2,811.00
Femoral Shaft - Half
NBB57 New South Wales Bone Bank $2,778.00
Femoral Shaft - Middle Third
NBB13 New South Wales Bone Bank $2,507.00
TBV24 Donor Tissue Bank of Victoria $2,137.00
Femoral Shaft - Segment
NBB56 New South Wales Bone Bank $1,687.00
Femoral Shaft - Third
NBB55 New South Wales Bone Bank $1,687.00
Femoral Shaft/Tibial Shaft - Middle third
PBT19 Perth Bone and Tissue Bank $2,702.00
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 $3,253.00
TBV22 Donor Tissue Bank of Victoria $3,854.00
Femur - Distal Half
NBB10 New South Wales Bone Bank $2,778.00
QBB20 The Queensland Bone Bank $2,800.00
Femur - Distal third
NBB11 New South Wales Bone Bank $2,606.00
Femur - Entire
MVS03 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB12 New South Wales Bone Bank $6,200.00
QBB22 The Queensland Bone Bank $4,268.00
Page 7 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
TBV23 Donor Tissue Bank of Victoria $6,455.00
Femur - Entire head removed
PBT18 Perth Bone and Tissue Bank $5,512.00
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 $3,253.00
TBV25 Donor Tissue Bank of Victoria $3,826.00
Femur - Proximal half
NBB15 New South Wales Bone Bank $2,921.00
QBB25 The Queensland Bone Bank $3,020.00
Femur - Proximal third
NBB14 New South Wales Bone Bank $1,306.00
Femur - Proximal with femoral head
TBV51 Donor Tissue Bank of Victoria $3,713.00
Fibula - Entire
MVS07 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB18 New South Wales Bone Bank $6,041.00
PBT25 Perth Bone and Tissue Bank $2,500.00
QBB32 The Queensland Bone Bank $2,651.00
TBV27 Donor Tissue Bank of Victoria $6,222.00
Fibula - Segment
NBB54 New South Wales Bone Bank $2,359.00
PBT28 Perth Bone and Tissue Bank $1,379.00
Fibula - Segment (12cm)
MVS14 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
TBV29 Donor Tissue Bank of Victoria $1,055.00
Fibula - Segment (6cm)
MVS13 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
TBV28 Donor Tissue Bank of Victoria $691.00
Fibular Shaft
TBV30 Donor Tissue Bank of Victoria $2,193.00
Page 8 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
Hemipelvis - Acetabulum
NBB21 New South Wales Bone Bank $2,905.00
PBT29 Perth Bone and Tissue Bank $2,756.00
QBB33 The Queensland Bone Bank $2,762.00
TBV31 Donor Tissue Bank of Victoria $2,992.00
Hemipelvis - Complete
MVS08 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB24 New South Wales Bone Bank $6,500.00
PBT30 Perth Bone and Tissue Bank $5,071.00
QBB37 The Queensland Bone Bank $4,268.00
TBV32 Donor Tissue Bank of Victoria $6,788.00
Hemipelvis - iliac crest
NBB22 New South Wales Bone Bank $2,705.00
PBT31 Perth Bone and Tissue Bank $1,100.00
QBB34 The Queensland Bone Bank $2,478.00
TBV33 Donor Tissue Bank of Victoria $2,705.00
Hemipelvis - Tricortical iliac wedge
NBB23 New South Wales Bone Bank $1,195.00
PBT32 Perth Bone and Tissue Bank $1,000.00
QBB35 The Queensland Bone Bank $1,195.00
TBV34 Donor Tissue Bank of Victoria $1,042.00
Hemipelvis - Tricortical iliac wedge Freeze Dried
QBB36 The Queensland Bone Bank $735.00
Humeral Head
TBV37 Donor Tissue Bank of Victoria $1,653.00
Humeral Head Addition
NBB26 New South Wales Bone Bank $1,545.00
Humeral Shaft
NBB50 New South Wales Bone Bank $3,090.00
QBB39 The Queensland Bone Bank $1,612.00
Humeral Shaft - Half
Page 9 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
NBB51 New South Wales Bone Bank $1,671.00
Humerus - Distal
MVS19 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB25 New South Wales Bone Bank $2,359.00
TBV49 Donor Tissue Bank of Victoria $2,241.00
Humerus - Entire
MVS20 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB29 New South Wales Bone Bank $3,142.00
QBB43 The Queensland Bone Bank $3,035.00
Humerus - Entire with rotator cuff
NBB30 New South Wales Bone Bank $3,182.00
PBT33 Perth Bone and Tissue Bank $3,236.00
Humerus - Proximal
NBB27 New South Wales Bone Bank $2,769.00
PBT35 Perth Bone and Tissue Bank $1,100.00
TBV36 Donor Tissue Bank of Victoria $2,769.00
Humerus - Proximal half with rotator cuff
NBB28 New South Wales Bone Bank $2,778.00
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 $2,704.00
TBV35 Donor Tissue Bank of Victoria $2,646.00
Humerus - Ring
NBB53 New South Wales Bone Bank $1,448.00
Ligament - Medial
NBB31 New South Wales Bone Bank $1,781.00
TBV38 Donor Tissue Bank of Victoria $1,781.00
Meniscal Graft
PBT47 Perth Bone and Tissue Bank $1,800.00
Meniscus
QBB05 The Queensland Bone Bank $1,400.00
Page 10 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
TBV40 Donor Tissue Bank of Victoria $1,184.00
Meniscus with Ligaments
TBV39 Donor Tissue Bank of Victoria $2,147.00
Osteotomy Wedge
PBT60 Perth Bone and Tissue Bank $1,000.00
Patella
QBB47 The Queensland Bone Bank $788.00
TBV41 Donor Tissue Bank of Victoria $1,020.00
Patellar unit whole with tibial block
PBT40 Perth Bone and Tissue Bank $2,487.00
Radius
MVS18 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB06 New South Wales Bone Bank $3,024.00
PBT13 Perth Bone and Tissue Bank $1,800.00
QBB15 The Queensland Bone Bank $2,258.00
TBV19 Donor Tissue Bank of Victoria $3,115.00
Radius - Ring
NBB49 New South Wales Bone Bank $1,854.00
Radius - Shaft
NBB47 New South Wales Bone Bank $2,975.00
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 $487.00
Spinal Ring
AUB07 Australian Biotechnologies $1,854.00
Tendon
AUB10 Australian Biotechnologies $2,184.00
Tendon - Achilles
NBB01 New South Wales Bone Bank $1,922.00
PBT61 Perth Bone and Tissue Bank $1,922.00
Page 11 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
QBB62 The Queensland Bone Bank $1,922.00
TBV05 Donor Tissue Bank of Victoria $1,024.00
Tendon - Achilles Hemi
QBB65 The Queensland Bone Bank $1,433.00
Tendon - Achilles with bone block
NBB02 New South Wales Bone Bank $2,228.00
PBT01 Perth Bone and Tissue Bank $2,228.00
QBB01 The Queensland Bone Bank $1,922.00
TBV06 Donor Tissue Bank of Victoria $2,085.00
Tendon - Achilles with bone plug
AUB09 Australian Biotechnologies $2,228.00
Tendon - Achilles with machined conical bone block
NBB69 New South Wales Bone Bank $2,728.00
Tendon - EHL
QBB69 The Queensland Bone Bank $1,922.00
Tendon - Gracilis
QBB59 The Queensland Bone Bank $1,922.00
Tendon - Patellar
QBB48 The Queensland Bone Bank $2,055.00
Tendon - Patellar Hemi
QBB63 The Queensland Bone Bank $1,570.00
Tendon - Patellar split with bone plugs
PBT02 Perth Bone and Tissue Bank $1,857.00
Tendon - Patellar with bone plugs
NBB33 New South Wales Bone Bank $2,147.00
TBV42 Donor Tissue Bank of Victoria $2,147.00
Tendon - Patellar with machined conical bone plug
NBB68 New South Wales Bone Bank $2,647.00
Tendon - Patellar with Quads
NBB72 New South Wales Bone Bank $2,184.00
Tendon - Peroneus Longus
Page 12 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
NBB73 New South Wales Bone Bank $2,184.00
Tendon - Semi tendinosis
NBB70 New South Wales Bone Bank $2,185.00
QBB70 The Queensland Bone Bank $1,922.00
Tendon - Single (ant and post tibilias, FDL, EDL,
PBT46 Perth Bone and Tissue Bank $2,060.00
Tendon - Tibialis Anterior
NBB67 New South Wales Bone Bank $2,184.00
QBB58 The Queensland Bone Bank $1,922.00
TBV57 Donor Tissue Bank of Victoria $2,085.00
Tendon - Tibialis Posterior
NBB71 New South Wales Bone Bank $2,184.00
QBB57 The Queensland Bone Bank $1,922.00
Tibia - Condyles only
TBV47 Donor Tissue Bank of Victoria $1,661.00
Tibia - Distal
MVS17 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
QBB51 The Queensland Bone Bank $1,892.00
TBV48 Donor Tissue Bank of Victoria $2,177.00
Tibia - Plateau (prox 1/3)
NBB35 New South Wales Bone Bank $2,518.00
Tibia - Proximal
NBB36 New South Wales Bone Bank $2,551.00
PBT45 Perth Bone and Tissue Bank $2,551.00
QBB54 The Queensland Bone Bank $2,365.00
Tibia - Proximal 16-25cm
TBV45 Donor Tissue Bank of Victoria $2,468.00
Tibia - Proximal 7-15cm
TBV44 Donor Tissue Bank of Victoria $2,562.00
Tibia - Proximal half
MVS11 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
Page 13 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
Tibia – Proximal third
AUB06 Australian Biotechnologies $2,562.00
Tibia - Proximal with Patella
QBB08 The Queensland Bone Bank $2,800.00
Tibia - Proximal with Patella & Tendon
PBT44 Perth Bone and Tissue Bank $3,859.00
Tibia - Proximal with Patellar Tendon
NBB46 New South Wales Bone Bank $3,986.00
Tibia - Ring
NBB45 New South Wales Bone Bank $1,448.00
Tibia - Whole
MVS16 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB37 New South Wales Bone Bank $4,065.00
QBB55 The Queensland Bone Bank $4,248.00
Tibia - Whole with Patella
QBB64 The Queensland Bone Bank $4,268.00
Tibia - Whole with Patellar Tendon
NBB44 New South Wales Bone Bank $5,455.00
Tibia Shaft
QBB53 The Queensland Bone Bank $992.00
Tibial Shaft
NBB41 New South Wales Bone Bank $3,747.00
Tibial Shaft - half
NBB43 New South Wales Bone Bank $2,450.00
Tibial Shaft - third
NBB42 New South Wales Bone Bank $2,645.00
Tibial Shaft Freeze Dried
QBB02 The Queensland Bone Bank $872.00
Tri Cortical Osteotomy
NBB66 New South Wales Bone Bank $1,208.00
Page 14 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
Ulna
MVS15 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
NBB07 New South Wales Bone Bank $2,787.00
PBT14 Perth Bone and Tissue Bank $1,500.00
QBB16 The Queensland Bone Bank $2,258.00
TBV20 Donor Tissue Bank of Victoria $2,871.00
Ulna - Ring
NBB40 New South Wales Bone Bank $1,854.00
Ulna - Shaft
NBB38 New South Wales Bone Bank $2,450.00
Grand Total: 276 Records
Page 15 of 15
Part C – Other Prostheses Subject to Listing Criteria
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