Private Health Insurance (Prostheses) Rules 2011 (No. 1) (Cth)
Private Health Insurance (Prostheses) Rules 2011 (No. 1)
I, PENNY SHAKESPEARE, delegate of the Minister for Health and Ageing, make these Rules under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.
Dated 31st January 2011
P Shakespeare__________
Penny Shakespeare
Assistant Secretary
Private Health Insurance Branch,
Medical Benefits Division
Department of Health and Ageing
Contents
Part 1 Preliminary 3
1.Name of Rules 3
2.Commencement 3
3.Revocation 3
4.Definitions 3
Part 2 Benefit requirements 5
5.Listing of, and benefits for, prostheses 5
5A.Circumstances in which a prosthesis is provided other than circumstances in which a medicare benefit is payable 6
5B.Conditions in relation to provision of listed prostheses 6
6.Benefits for prostheses provided as part of hospital treatment 6
7.Benefits for prostheses provided as part of hospital-substitute treatment 7
Part 3 Other 8
8.Timing of applications to have a prosthesis listed 8
9.Minister may have regard to recommendations and advice 8
10.Listing criteria for prostheses to be listed on Part C of the Schedule 8
Part 1 Preliminary
Name of Rules
These Rules are the Private Health Insurance (Prostheses) Rules 2011 (No. 1).
Commencement
These Rules commence on 21 February 2011.
Revocation
These Rules revoke the Private Health Insurance (Prostheses) Rules 2010 (No. 2) as amended by the Private Health Insurance (Prostheses) Amendment Rules 2010 (No. 1) and the Private Health Insurance (Prostheses) Amendment Rules 2010 (No. 2).
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 of a kind listed in the Schedule where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and a different amount is set out 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.
listed prosthesis means a kind of prosthesis listed in the Schedule to these Rules.
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 of a kind listed in the Schedule where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and no amount is set out 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 General Medical Services Table being the table prescribed under section 4 of the Health Insurance Act 1973.
professional service has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.
public hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a public hospital.
Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.
Schedule means the Schedule in these Rules.
Part 2 Benefit requirements
5. 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 kinds of prostheses:
(i)in relation to which the Minister has granted an application for listing under subsection 72-10 (5) of the Act; or
(ii)which are listed in accordance with 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.
(aa) circumstances in which a listed prosthesis is provided for the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) are set out in rule 5A; and
(ab) conditions that must be satisfied in relation to the provision of a listed prosthesis for the purposes of paragraphs (c) and (d) of item 4 of the table in subsection 72-1(2) are set out in rule 5B; and
(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; 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.
5A. Circumstances in which a prosthesis is provided other than circumstances in which a medicare benefit is payable
For purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) of the Act, the following circumstances are set out:
(a) the provision of a listed prosthesis which is associated with podiatric treatment by an accredited podiatrist.
Note: Paragraph (c) of Item 4 of subsection 72-1(2) deals with the provision of a listed prosthesis in circumstances in which a medicare benefit is payable.
5B. Conditions in relation to the provision of listed prostheses
For the purposes of paragraph (c) and (d) of item 4 of the table in subsection 72-1(2) of the Act, conditions that must be satisfied in relation to the provision of a listed prosthesis in the circumstances covered by paragraph (c) or (d) of that item, as the case may be, are:
(a) in relation to any kind of prosthesis where there is a statement of a requirement under the heading 'Condition' in the Schedule under the listing for that kind of prosthesis, that requirement; and
(b) in relation to a listed prosthesis that is an insulin infusion pump, also:
(i) the professional service associated with the provision of the insulin infusion pump must be a professional attendance by a consultant physician in the practice of his or her specialty; and
(ii) the professional service must be provided as a certified Type C procedure or certified overnight Type C procedure; and
(iii) the insulin infusion pump must be provided for the purpose of administering insulin.
Note: Item 4 of the table in subsection 72-1(2) of the Act states other requirements in relation to benefits for the provision of prostheses that a policy that covers hospital treatment must meet. These requirements relate to benefits for hospital treatment and, if the policy covers hospital-substitute treatment, to the benefits of that coverage as well.
6. 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, 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:
(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:
(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:
(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.
Note: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.
7. 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 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:
(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 1: 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 ―see paragraph 121-10 (3) (a) of the Act.
Note 2: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.
Part 3 Other
8. 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 kind of 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 kind of prosthesis from the list in the Rules if the applicant fails to pay an ongoing listing fee.
9. 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 List Advisory Committee.
(2)In setting the minimum and the maximum (if any) benefits for a kind of prosthesis, the Minister may have regard to the benefits as negotiated between the Negotiating Oversight Committee and the applicant.
10. Listing criteria for prostheses to be listed in Part C of the Schedule
For a listing application to be granted to list a kind of prosthesis in Part C of the Schedule, the listing criterion is that the kind of prosthesis is an:
(i) insulin infusion pump; or
(ii) implantable cardiac event recorder.
Note: 1. The power to make listing criteria is in subsection 72-10(6) of the Act.
2. Under subsection 72-10(7) of the Act the Minister must not grant a listing application if any applicable listing criteria are not satisfied in relation to the application.
3. Under the Act the Minister may refuse to grant a listing application even if the listing criteria are satisfied. See Note to subsection 72-10(7) of the Act.
Note
1.All legislative instruments and compilations are registered on the Federal Register of Legislative Instruments kept under the Legislative Instruments Act 2003. See A - Prostheses February 2011
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 1- Cardiothoracic Mechanical Valves
Group 1c - Bi-Leaflet, rotatable
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
MC980 Open Pivot Heart Valve (Model 500FA) Pyrolythic Carbon, Double Velour 16-33mm $6,000.00
Polyester, Titanium
Open Pivot Heart Valve (Model 500DM)
MC981 Open Pivot Heart Valve (Model Pyrolythic Carbon, Double Velour 16-33mm $6,000.00
501DA) Polyester, Titanium
Open Pivot Heart Valve (Model 501DM)
Reid Healthcare
RH001 Aortic On-X Prosthetic Heart Valve 27-29mm, 19mm, 21mm, $6,000.00
Models ONXA-19; ONXA-21; 23mm, 25mm, 25-33mm, 27-
ONXA-23; ONXA-25; ONXA-27/29; 29mm, 31-33mm, 23mm,
ONXM-23; ONXM-25; ONXM- 25mm
27/29; ONXM31/33; ONXMC25/33
Sorin Group
SA129 Optiform Mechanical Valve 19mm to 33mm $6,000.00
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 Rotatable Cuff -27mm, Rotatable 17 - 33mm
Cuff Heart Valve; St Jude Medical
Mechanical Heart Valve Masters Series
Prostheses List by Category, Groups and Sponsor Page 1 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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 A7700/M7700 Titanium. Pyrolite. Dacron, A7700 - Diameter 20-31mm, $5,100.00 $5,625.00
Model A7700, Medtronic Hall Heart A7700EZ/M7700EZ Titanium. Pyrolite. M7700 - Diameter 23-33mm,
Valve Mitral Model M7700, Hall Easy PET A7700EZ - Diameter 19-
Fit Aortic Heart Valve Model A7700, 29mm, M7700EZ - Diameter
Hall Easy Fit Mitral Heart Valve Model 23-31mm
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;
Volume: 32.6cc
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
Prostheses List by Category, Groups and Sponsor Page 2 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
SJ121 Current VR 1107-36 Single Chamber Cardioverter Defibrillator 38cc 76g $42,640.00
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
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, d, e
Boston Scientific Australia Pty Ltd
BS132 Teligen 100 HE VR 4-SITE Single chamber ICD, high energy with RF 30.5cc, 9.9mm $43,390.00
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
Prostheses List by Category, Groups and Sponsor Page 3 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
monitoring
Generation 4
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
MI015 PROTECTA XT VR D354VRG Single chamber implantable cardioverter Volume 37cc, Mass 68g $43,920.00
defribillator with SmartShock Technology,
OptiVol 2.0 Fluid Status Monitoring and
Complete Capture Management
Specifications (DF-1)
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
SJ242 Fortify VR CD1233-40 Single chamber cardioverter defibrillator 35cc, 75g $43,920.00
with 40J delievered energy
SJ251 Fortify ST VR CD1235-40 Single chamber cardioverter defibrillator 35cc, 75g $43,920.00
with 40J delivered energy and ST segment
monitoring
Prostheses List by Category, Groups and Sponsor Page 4 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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.
SJ240 Fortify VR CD1233-40Q Single chamber cardioverter defribillator 35cc, 75g $44,670.00
with 40J delivered energy with SJ4
connector
SJ247 Fortify ST VR 1235-40Q Single chamber cardioverter defibrillator 35cc, 75g $44,670.00
with 40J delivered energy and ST segment
monitoring and SJ4 connector
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
monitoring
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
Prostheses List by Category, Groups and Sponsor Page 5 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
5866-45, Model 5866-46
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
AY037 Xience PRIME LL Everolimus Eluting Coronary Artery Stent, Drug Eluting XIENCE PRIME LL 2.50; $3,450.00
Coronary Stent; Xience PRIME 2.75; 3.00; 3.50; 4.0 x 33MM;
Everolimus Eluting Coronary Stent; XIENCE PRIME LL 2.50;
Xience PRIME SV Everolimus Eluting 2.75; 3.00; 3.50; 4.0 x 38MM;
Coronary Stent 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- $3,450.00
Coronary Stent System Polymer and Paclitaxel 38mm
Prostheses List by Category, Groups and Sponsor Page 6 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
BS125 Promus Everolimus Coronary Stent Cobalt chromium alloy stent coated with a 2.25mm to 4.0mm diameter, $3,450.00
System blended polymer mixed with Everolimus. 8mm to 28mm length
BS175 PROMUS Element Platinum chromium alloy stent coated with 8mm to 38mm with a reference $3,450.00
a blended polymer mixed with everolimus. vessel diameter of 2.25mm -
4.0mm.
BS176 Taxus Element Platinum chromium alloy stent coated with (8mm to 38mm) with a $3,450.00
a blended polymer mixed with Paclitaxel reference vessel diameter of
2.25mm - 4.5mm
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, struts
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 $3,450.00
Stent & Delivery System Sirolimus (an immunosuppressive and anti- 8 - 33mm
proliferative drug) bound to the stent by a
polymer. Model CRA-23300, 08225,
08250, 08275, 08300, 28225, 28250,
28275, 28300, 33225, 33250, 33275,
33300, 13225, 13250, 13275, 182
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 System 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 Polymer Diameter:2.25mm-4.0mm; $3,450.00
Coronary Stent System Length: 8.00mm-30.0mm
Prostheses List by Category, Groups and Sponsor Page 7 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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 - Vision Cobalt chrome stent 2.25mm to 4.0mm widths, 8mm $1,248.00
to 38mm lengths
AY039 MULTI-LINK 8 Coronary Stent The MULTI-LINK 8, MULTI-LINK 8 MULTI-LINK 8: Diam: 2.5, $1,248.00
System, MULTI-LINK 8 SV Coronary SV, MULTI-LINK 8 LL Coronary Stent 2.75, 3.0, 3.5, 4.0mm, Stent
Stent System and MULTI-LINK 8 LL System (CSS) is comprised of two main Length: 8, 12, 15, 18, 23,
Coronary Stent System components: the cobalt chromium (CoCr) 28mm; MULTI-LINK 8 SV
stent and the balloon expandable delivery CSS: Diam: 2.25mm, Stent
system. Length: 8, 12, 15, 18, 23,
28mm; MULTI-LINK 8 LL
CSS: Diam: 2.5, 2.75, 3.0, 3.5,
4.0mm, Stent Length: 33 and
38mm
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 25mm
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
28mm
Biotronik Australia Pty Ltd
BT082 PRO-Kinetic Cobalth Chromium coronary stent system 8-40mm length 2-5mm $1,200.00
diameter
Prostheses List by Category, Groups and Sponsor Page 8 of 920
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 $1,248.00
tubular, balloon-expandable stent sculpted is available in 66 different
by laser from a single tube of L-605 cobalt diameter/length combinations.
chromium (CoCr) alloy. The stent It 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
and was subject to extensive clinical testing.
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:
delivery catheter. 2.25, 2.5, 2.75, 3.0, 3.5, 4.0,
4.5 & 5.0 mm
Prostheses List by Category, Groups and Sponsor Page 9 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
DY534 Presillion Plus CoCr Coronary Stent on Cobalt Chromium, bare metal coronary Stent length 8 - 40mm x Stent $1,248.00
RX System stent Diameter 2.5 - 5.0 mm
JJ026 BX Velocity with Hepacoat System Balloon expandable, stainless steel, heparin . $1,220.00
coated
JJ200 BX Velocity Stent and Delivery System Stainless steel stent Diameter: 2.25-5.0 mm; Length $1,220.00
8 - 33 mm
JJ239 BX Sonic Stainless steel coronary stent mounted on a Dia 2.25 - 4.0mm, lengths 8 - $1,220.00
balloon delivery system 33mm
JJ670 Presillion CoCr Coronary Stent on RX Cobalt Chromium, bare metal coronary Stent Length (mm) x Stent $1,248.00
System stent 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, 4.0;
Medical Specialties Australia Pty Ltd
MS058 Arthos Pico Stent Implantation System Cobalt Chromium Stent Premounted on a Diameter: 2-4mm; Length: 8- $1,248.00
Rapid Exchange Delivery System 38mm
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 -
24mm)
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; $1,248.00
Length: 8 - 30mm
Prostheses List by Category, Groups and Sponsor Page 10 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
OrbusNeich Medical Pty Ltd
NM004 Blazer Coronary Stent Delivery System L605 Cobalt Chromium alloy balloon Expanded Stent Diameter 2.5 $1,248.00
expandable vascular prosthesis to 4.0mm, Stent Length 9 to
33mm
Terumo Corporation Australia
TU001 Tsunami Gold Stainless Steel mounted on balloon catheter Diameter 2.0mm - 4.0mm, $1,248.00
Length 8mm - 30mm length
TU044 Kaname Coronary Stent System BMS Coronary Stent Diameter: 2.5mm; 2.75mm; $1,248.00
3.0mm; 3.5mm; 4.0mm x
Lengths : 9mm; 12mm; 15mm;
18mm; 24mm; 28mm.
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.1
Abbott Australasia Pty Ltd
AY027 Multilink Coronary Stent System - 316L Stainless steel stent Length 1.5 - 8.0mm $2,200.00
Frontier
c.2
Imaxeon Pty Ltd
IX002 Nile CroCo Intracoronary stent pre-mounted on two Diameter : 2.50 - 3.50mm. $1,750.00
rapid exchange delivery systems for MB and 2.00-3.00mm SB
bifurcation lesions treatment Lengths 18 mm and 24 mm
c.3
Imaxeon Pty Ltd
IX003 Minvasys Nile Delta Coronary Stent Balloon expandable Amazonia Nile Delta 2.50mm diameter x $1,248.00
System 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 11 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Group 13: Special Purpose Percutaneous Cardiovascular Devices
Sub-Group 1: Intracardiac Defect Occluders
a
J T Medical Pty Ltd
JT001 Occlutech Figulla Flex ASD Occluder The Occlutech Figulla® Flex ASD 6, 7.5, 9, 10.5, 12, 15, 18, 21, $10,000.00
occluder is an implant for closure of an 24, 27, 30, 33, 36, 39, 40
Atrial Septal Defect of the heart (ASD
II=ASD of the Secundum Type) and is
deployed via a minimally invasive catheter
delivery system.
The Occlutech Figulla® Flex ASD is
intended for patients with substantiated
Left-Right-Shunt and a clear indication for
closure of the defect.
JT002 Occlutech Figulla Flex PFO Occluder The Figulla® Flex PFO is an implant for 16/18, 23/25, 27/30 and 31/35 $10,000.00
closure of a patent foramen ovale (PFO)
defect in the heart and is deployed via a
minimally invasive catheter delivery system.
The Figulla® Flex PFO is intended for
patients with substantiated Right-Left-
Shunt in the contrast agent
echocardiography under Valsalva
maneuver and presence of a "cryptogenic",
paradoxical thromboembolism.
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 mesh Waist diameter 3-6mm, $10,200.00
PDA occlusion device Nominal length 4-6mm
Prostheses List by Category, Groups and Sponsor Page 12 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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 38mm
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
single end item.
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
apposition device
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
b
Abbott Australasia Pty Ltd
AY038 Coherex FlatStent EF PFO Closure In-tunnel PFO closure device and delivery 13mm & 19mm $10,200.00
System system
Prostheses List by Category, Groups and Sponsor Page 13 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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,
6.0mm, 6.5mm
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:
4.5; 5.0; 6.0
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
fibrillation monitoring.
SJ159 SJM Confirm Model DM2100 Implantable cardiac monitor 6.5cc, 12g $3,900.00
Prostheses List by Category, Groups and Sponsor Page 14 of 920
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
position 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 15 of 920
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 Prosthetic Aortic Valves - Tissue Annulus $4,445.00
Prosthetic Heart Valve Heart Valve is manufactured from Diameter - 21-29mm, Implant
selected procine aortic valve cusps that Height - 11-15c; Mitral Valves
have been cross-linked with a - Tissue Annulus Diameter -
glutaraldehyde solution 25-35mm, Implant Height - 8-
10mm
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 valve 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 valve Tissue Annulus Diameter - $4,445.00
for supra-annular placement in the aortic 19mm-23mm. Total Height
position 14mm-16mm.
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 Alloy;
Bioprosthesis Model 6650 Mitral Valve Silicone Rubber, Polytetrafluoroethylene
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
P
Medtronic Australasia Pty Ltd
MI007 Hancock II Aortic Valve Aortic bioprosthesis 21mm to 29mm $4,445.00
MI008 Hancock II Mitral Valve Mitral bioprosthesis 25mm to 33mm $4,445.00
Prostheses List by Category, Groups and Sponsor Page 16 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
MI009 Hancock II Ultra Aortic Valve Small aortic root bioprosthesis 21mm to 29mm $4,445.00
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
7000TFX
Sorin Group
SA130 Mitroflow Pericardial Bioprosthesis 19-27mm $5,000.00
(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
3300TFK
B (Bovine)
Sorin Group
SA155 Mitroflow Mitroflow Aortic Pericardial Heart Valve 19, 21, 23, 25, 27mm $5,000.00
(Model LX)
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 33mm
Perimount Plus Pericardial Bioprosthesis Rubber, Polytetrafluoroethylene
Mitral - Model 6900P
EL039 Edwards Perimount Magna Model 3000 Carpentier-Edwards Perimount Magna 19MM Aortic Pericardial $5,000.00 $5,690.00
composition: Glutaraldehyde treated Tissue Valve; 21MM Aortic
bovine pericardium/elgiloy wireform Pericardial Tissue Valve;
stent/polyester band/silicone rubber suture 23MM Aortic Pericardial
ring/polytetrafluoroethylene cloth/polyester Tissue Valve; 25MM Aortic
cloth. Pericardial Tissue Valve;
27MM Aortic Pericardial
Tissue Valve; 29MM Aortic
Pericardial Tissue Valve
Prostheses List by Category, Groups and Sponsor Page 17 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
Medtronic Australasia Pty Ltd
MC982 3f Aortic Bioprosthesis (Model 1000) Model 1000 - EQUINE Pericardium 19 - 29 mm $5,000.00
Bioprostheseis (non stented)
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 response 32.6cc; Dimensions: 58.4 x
73.4 x 11mm
St Jude Medical Australia Pty Ltd
SJ115 Atlas II+ DR V-268 Dual Chamber Cardioverter Defibrillator 39cc, 78g $45,760.00
Prostheses List by Category, Groups and Sponsor Page 18 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
Threshold Monitoring
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
Monitoring
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
IS4
c
Guidant Australia Pty Ltd
GU157 Vitality AVT - Model A155 Dual Chamber ICD with atrial therapies 30cc $43,680.00
Prostheses List by Category, Groups and Sponsor Page 19 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
d
Biotronik Australia Pty Ltd
BT091 Lumax 300 DR-T ICD-DR with bidirectional Home One size only $43,680.00 $46,680.00
Monitoring
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
monitoring
Generation 4
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
MI016 PROTECTA XT DR D354DRG Dual chamber implantable cardioverter Volume 37cc, Mass 68g $47,130.00
defribillator with SmartShock Technology,
OptiVol 2.0 Fluid Status Monitoring and
Complete Capture Management
Specifications (DF-1)
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
Monitoring
SJ153 Current Accel DR RF CD2215-36 Dual Chamber Cardioverter Defibrillator 80g, 42cc $47,130.00 $48,480.00
with RF Telemetry
SJ241 Fortify DR CD2233-40 Dual chamber cardioverter defibrillator 35cc, 76g $47,130.00
with 40J delivered energy
SJ248 Fortify ST DR CD2235-40 Dual chamber cardioverter defibrillator 35cc, 76g $47,130.00
with 40J delivered energy and ST segment
monitoring
Prostheses List by Category, Groups and Sponsor Page 20 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
SJ249 Fortify DR CD2233-40Q Dual chamber cardioverter defibrillator 35cc, 76g $47,880.00
with 40J delivered energy
SJ250 Fortify ST DR CD2235-40Q Dual chamber cadioverter defibrillator with 35cc, 75g $47,880.00
40J delivered energy and ST segment
monitoring
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
monitoring
Group 3 - Cardiothoracic Valve Conduits
Group 3a - Mechanical Valve
Medtronic Australasia Pty Ltd
MC198 Medtronic Hall rotatable aortic valved Titanium, pyrolite, dacron 20 - 33mm $6,950.00
collagen impregnated conduit Model
R7700
MC979 Open Pivot Aortic Valved Graft (Model Pyrolythic Carbon, Double Velour 21- 33mm $6,950.00
502AG) Polyester, Titanium
Prostheses List by Category, Groups and Sponsor Page 21 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
Graft
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
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 30mm.
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 CRT-D One Size only $45,760.00
H190, 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
Prostheses List by Category, Groups and Sponsor Page 22 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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 with 34cc, 94 grams; 61.8 x 73.4 x $47,840.00
Cardiac Resynchronisation therapy, High 11mm
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
a, c
Guidant Australia Pty Ltd
GU155 Contak Renewal 4 AVT HE CRT - D - Implantable Cardioverter Defibrillator with 40cc; 89g $47,840.00
Model M177, M179 cardiac resynchronisation Therapy
a, c, d
Medtronic Australasia Pty Ltd
MC720 Concerto CRT-D Implantable Cardioverter Defibrillator with 38cc $47,840.00 $50,000.00
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
Prostheses List by Category, Groups and Sponsor Page 23 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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 Longevity.
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
1/LV-1)
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 with 37cc; 89g $45,760.00
Model M170 and M175 Cardiac Resynchronisation Therapy
d
Biotronik Australia Pty Ltd
BT088 Lumax 300 HF-T CRT-D with bidirectional Home Monitoring One size only $45,760.00 $48,760.00
Generation 3
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
Prostheses List by Category, Groups and Sponsor Page 24 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
MI017 Protecta XT CRT-D D354TRG Implantable Cardioverter Defibrillator with Volume 38cc, Mass 68g $52,000.00
Cardiac Resynchronisation therapy,
SmartShock Technology, OptiVol 2.0
Fluid Status Monitoring and Complete
Capture Management Specifications (DF-
1)
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
SJ246 Unify CRT CD3235-40 Cardiac Resynchronisation Therapy 36cc, 78g $52,000.00
Defibrillator with 40J delivered
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
SJ244 Unify CRT CD3235-40Q Cardiac Resynchronisation Therapy 36cc, 77g $52,750.00
Defibrillator with 40J delivered energy and
SJ4 connector
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 25 of 920
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; Polyester
Fabric
Medtronic Australasia Pty Ltd
MC005 Medtronic Duran Annuloplasty Ring; Annuloplasty Devices - Models 610R & Model 610R 25-35mm & $2,200.00
Duran Ancore Ring 620R; Duran 620R Silicone / Barium Sulphate, Dacron. Model 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/32 $2,400.00
cloth/plastic template Mitral valve annular mm/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
Prostheses List by Category, Groups and Sponsor Page 26 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
EL059 Carpentier-Edwards PHYSIO ll Mitral PHYSIO II is a semi rigid mitral 24, 26, 28, 30, 32, 34, 36, 38, $2,400.00
Annuloplasty Ring annuloplasty ring, with an improved saddle 40mm
shape and global disease based design
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 38mm
MC844 Profile 3D Annuloplasty Ring 3D, rigid annuloplasty ring with physiologic Diameter (mm) 24 - 40mm $2,400.00
mitral valve shape
Sorin Group
SA150 MEMO 3D Memo 3D Semirigid Mitral Annuloplasty 24-38mm $2,400.00
Ring, with 3D flexibility and coasted with
Carbofilm
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 increment
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; $2,200.00
Galloway Future Band Model 638B; Silicone / Barium Sulphate, Dacron. Models 620B & 620BG: 23-
Duran Ancore Band 620B; Duran Models 638B semi-regid metal alloy core, 35mm, Model 638B - 26-
Ancore Chordal Model 620BG silicone coating, polyester knit fabric, kit 38mm
includes-band, malleable handle, template
with suture markers, sizers
Prostheses List by Category, Groups and Sponsor Page 27 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Reid Healthcare
RH002 Kalangos Mitral Ring KALANGOS Mitral Ring is intended for Diameter 16mm - 36mm, $2,200.00 $2,500.00
heart valve repair. Each device is Height 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 steel needle on both sides.
Prostheses List by Category, Groups and Sponsor Page 28 of 920
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
steel needles. These three constituents are Radius 3 (mm) 7.98 Height
assembled in such a way that they cannot (mm) 1.30 Thickness (mm)
be shared or dismounted after assembly TRK20 7.1 Radius 1 (mm)
without irremediably destroying the device. 8.92 Radius 2 (mm) 5.1 Radius
For these reasons, KALANGOS 3 (mm) 8.96 Height (mm) 1.30
Tricuspid Ring should be considered as a Thickness (mm)
single device. Each extremity of the TRK22 8.1 Radius 1 (mm)
polymeric segment is terminated by a sharp 9.27 Radius 2 (mm) 6.1 Radius
end prolonged by the PVDF suture with a 3 (mm) 10.05 Height (mm)
swaged stainless steel needle on both 1.30 Thickness (mm)
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 29 of 920
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 rate- 11cc, 23g $5,928.00
implantable pacemaker 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, single 53 x 39 x 6.5W x H x D [mm], $5,928.00
cFully automatic, extended longevity, single Size 1 [cm3], 25 Mass[g]
chamber pacemaker with Closed Loop
Stimulation.
BT113 Evia SR Fully automatic, extended longevity, single 53 x 39 x 6.5 W x H x D [mm], $5,928.00
chamber pacemaker with Closed Loop Size 10[cm3], 25 Mass [g]
Stimulation.
Boston Scientific Australia Pty Ltd
BS124 Insignia AVT 1192 Single chamber rate responsive pacemaker 10cc, 23.4g $5,928.00
Prostheses List by Category, Groups and Sponsor Page 30 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
BS145 Altrua 20 SR Single chamber rate responsive pacemaker 10cc - 15cc $5,928.00
BS147 Altrua 40 SR Single chamber rate responsive pacemaker 10cc - 15cc $5,928.00
BS149 Altrua 50 SR Single chamber rate responsive pacemaker 10cc - 15cc $5,928.00
BS152 Altrua 60 SR Single chamber rate responsive pacemaker 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
Pacemaker
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 with 37 x 41.5 x 6.1mm $5,928.00
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.
Volume: 7.5 cm3
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 rate- 11cc, 23g $5,928.00
implantable pacemaker adaptive pacing devices with extended
longevity
SJ090 Victory SR 5610 single chamber rate responsive pacemaker 41x44x46mm 17g 8cc $5,928.00
SJ105 Zephyr SR 5620 Single Chamber Rate-Responsive 8cc, 17g $5,928.00
Pacemaker
Prostheses List by Category, Groups and Sponsor Page 31 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
SJ131 Zephyr XL SR 5626 Single-Chamber Rate-Responsive 23.5g and 10.4cc $5,928.00
Pacemaker
SJ205 Accent SR PM 1110 Single Chamber Rate Responsive 18g, 9.5cc $5,928.00
Pacemaker
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 Pacemaker
d
Biotronik Australia Pty Ltd
BT108 Entovis SR-T Fully automatic, extended longevity, single 53 x 39 x 6.5 W x H x D [mm], $5,928.00 $8,928.00
chamber pacemaker with Closed Loop Size 11 [cm3], 24 mass[g]
Stimulation & BIOTRONIK Home
Monitoring
BT110 Evia SR-T Fully automatic, extended longevity, single 53 x 39 x 6.5 W x H x D [mm], $5,928.00 $8,928.00
chamber pacemaker with Closed Loop Size 11 [cm3], 24 Mass [g]
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
telemetry
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
Prostheses List by Category, Groups and Sponsor Page 32 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
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
Prostheses List by Category, Groups and Sponsor Page 33 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
suppression
Generation 2
Medtronic Australasia Pty Ltd
MC713 Adapta Pacemaker VDDR PacemakerModels ADVDD01 11.1cc23.6g $6,760.00
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, DDDR 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
Prostheses List by Category, Groups and Sponsor Page 34 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
1294,1295,1296 Permanent Pacemaker
GU140 Insignia Ultra DR Model 1291 Dual Chamber Rate Responsive One size only $9,360.00
Pacemaker
GU141 Insignia Ultra DR Model 1290 Dual Chamber Rate Responsive One size only $9,360.00
Pacemaker
Sorin Group
SA136 Symphony DR 2550 Active Implantable pacemaker 1 size only $9,360.00
SA141 Reply™ DR Dual Chamber permanent Pacemaker with 8cc, Weight: 20grams, $9,360.00
Rate Response Modulation Dimensions:41.2 x 41.5 x 6.1mm
SA144 ESPRIT DR Dual Chamber Permanent Pacemaker with 8cc, Weight: 20grams, $9,360.00
Rate Response Modulation Dimensions:41.2 x 41.5 x 6.1mm
St Jude Medical Australia Pty Ltd
SJ051 Verity Adx Implantable Pacemaker, Dual - Chamber, multi-programmable, 45x52x6mm,11cc, 23g, 5mm $9,360.00
Models XL DR 5356 and XL DR rate-responsive pacemaker withAF or 6mm M/S
5357M/S suppression
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
suppression 5386: 44x52x6mm, 23.5g and
11cc
SJ089 Victory XL DR 5816 and DR 5810 Dual Chamber Rate Responsive 44x52x6mm; 23.5g; 11cc $9,360.00
Pacemakers
Prostheses List by Category, Groups and Sponsor Page 35 of 920
CARDIO-THORACIC
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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 MVP
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
19.5cm Curved Extension
KA014 Mahurkar Maxid Catheters Catheters constructed of radiopaque Size, 38, 43, 48, 53cm $305.00
polyurethans, high kink resistant. The
arterial lumen is shorter than the venous
lumen at the catheter's distal end in order
to reduce recirculation during haemodialysis
cu
Bard Australia Pty Ltd
BA040 VitaCuff, Hickman Catheter Dialysis/Apheresis catheter, dual lumen, 36-45cm overall length $349.00 $359.00
silicone
BA140 HemoGlide Long Term Haemodialysis Dialysis Catheter, Multiple Lumen 14.5 Fr $357.00 $368.00
Catheter
Prostheses List by Category, Groups and Sponsor Page 915 of 920
VASCULAR CAG
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
BA159 HemoSplit Long Term Haemodialysis HemoSplit is a carbothane long term dual Standard Kit (straight15cm $485.00 $500.00
catheter lumen catheter used to provide vascular to42cm and pre-curved 19cm
access for haemodialysis. It comprises of a to31cm), Microintroducer Kits
double D lumen configuration catheter (straight 19cm to 42cm & pre-
each lumen having an ID of 2.3mm) with a curved 19cm to 31cm)
fixed split tip (to 7.5cmm) which enables
blood flo
Kendall Australasia Pty Ltd TA Covidien Pty Ltd
KA011 Permcath Dual Lumen Catheter Chronic Haemodialysis, long term vascular 36cm, 40cm $330.00
access for haemodialysis and aphaeresis.
Constructed of radiopaque silicone rubber.
Kit contains: Catheter, 18ga Introducer
Needle, J/Straight 0.038" Guidewire, 10cc
Syringe, 10Fr. Dilator (28cm only), 12Fr.
Dilator (except 28cm), #11 Scalpel,
Tunnelling Stylet, Oval Pull-Apart
Sheath/Dilator, (4) Gauze Sponges, (2)
Wound Dressing, (2) Injection Sealing
Caps.
KA013 Permcath Dual Lumen Catheter Chronic haemodialysis, long term vascular 28, 36, 40cm $290.00
access for haemodialysis and aphaeresis.
Constructed of radiopaque silicone rubber.
KA018 Palindrome Haemodialysis catheter 14.5Fr. 19, 23, 28, 33, 55cm $485.00 $600.00
Insertion Lengths, with 36, 40,
45, 50, 72cm Overall length,
with side slots, symmetric tip
Mayo group
CM023 Arrow Cannon II Plus Chronic Dual Lumen, Retrograde Tunneled, 15Fg x 24 - 55cm $450.00
Haemodialysis Catheter Set Cuffed, Tip First, Chronic Haemodialysis
Catheter Set
Tekmed Pty Ltd
TK005 Medcomp Long Term Catheter sets for ASH, TESIO-BioFlex with cuff 10, 14 French 24,28,32 & $450.00
Haemodialysis 36cm lengths
TK006 Medcomp Long Term Catheter sets for HemoFlow HFS-Carbothane with cuff 14.5 French 24,28,32 & $295.00
Haemodialysis 36cm lengths
Prostheses List by Category, Groups and Sponsor Page 916 of 920
VASCULAR CAG
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
i
Mayo group
CM015 ARROWg+ard Blue Haemodialysis Haemodialysis Catheters (of various CS-22122 - 12Fr 16cm, Dual $195.00
Catheters lengths, sizes and lumen confiurations) with Lumen
antimicrobial impregnation (chlorhexidine CS-22123 – 12Fr 16cm, Triple
and silver sulphadiazine) on the external Lumen
surface of the polyurethane catheter CS-25122 – 12Fr x 20cm,
material. Dual Lumen
CS-22142CF – 14Fr x 15cm,
Dual Lumen, Curved, Firm
CS-22142F – 14Fr x 15cm,
Dual Lumen Firm
CS-25122 – 12Fr x 20cm,
Double Lumen
CS-25123 – 12Fr x 20cm,
Triple Lumen
CS- 25142CF – 14Fr x 20cm,
Double Lumen, Curve, Firm
CS-25142F – 14Fr x 20cm,
Double Lumen, Firm
CS-26142F – 14Fr x 25cm,
Double Lumen, Firm
CU-22122 – 12Fr x 16cm,
Double Lumen, Curved
CU-23122 – 12Fr x 13cm,
Double Lumen, Curved
CU-25122 – 12Fr x 20cm,
Double Lumen, Curved
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, needles, Height: 11.5mm. Dimension:
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 Single Chamber
Prostheses List by Category, Groups and Sponsor Page 917 of 920
VASCULAR CAG
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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 Single
Chamber
BMDi Tuta Healthcare Pty Ltd
TT001 Paragon Ambulatory Drug Infusion System The top of the Paragon infuser is made of Infuser - 100mL Administration $534.00
acetyl with stainless steel parts; the bottom Sets - 0.50mL, 1mL, 2mL,
is made of clear polycarbonate. Diam: 4mL, 10mL, 50mL, 100mL, or
10cm Height: 5.8cm. Administration Sets 200mL/hr
- made from PVC and acrylic
components.
Cook Medical Australia Pty Ltd
WC093 Cook Implantable Injection/Infusion Ports 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
introducer set
WC094 Cook Implantable Injection/Infusion Ports Mini or Petite or Standard, single or 3 - 12 Fr pre-attached or $534.00
multiple chamber titanium Port which may detached catheter or valve system
include micropuncture or standard
introducer set
WC115 Cook Implantable Injection/Infusion Port 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
introducer set system
Denward Dell Pty Ltd TA Surimex
DW003 Jet Port Plus Set - Vascular Access Port Implantable injection / infusion port system: Port: Diameter: 28.0mm, $375.00
port chamber with silicone membrane; Height: 12.3mm; Catheter: 6.6
connectable polyurethane catheter; and French, Length: 750mm
introducer kit.
DW004 Jet Port Plus Low Profile Peripheral Set Implantable injection / infusion port system: Port: Length: 24.0mm, Width: $420.00
- Vascular Access Port low profile port chamber with silicone 20.5mm, Height: 10.3mm
membrane; connectable polyurethane Catheter: 6.6 French, Length:
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
Prostheses List by Category, Groups and Sponsor Page 918 of 920
VASCULAR CAG
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
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
Denward Dell Pty Ltd TA Surimex
DW006 T-Port Contrast set - Vascular access Injection infusion port system: titanium port 6163653077: Port Base 27mm $630.00
port. chamber with silicone membrane: x 13mm, Catheter Diameter
connectable polyurethane catheter; 1.3 x 2.2mm, Catheter Length
introducer kit. 75cm. 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 Ports 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
Prostheses List by Category, Groups and Sponsor Page 919 of 920
VASCULAR CAG
Minimum Maximum
Billing Code Product Name Description Size Benefit Benefit Notations
Denward Dell Pty Ltd TA Surimex
DW005 Dual Port Set - Vascular Access Port Implantable injection / infusion port system: Port: Length: 53.0mm, Width: $580.00
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: 9365 Records
Prostheses List by Category, Groups and Sponsor Page 920 of 920
PART B - Human Tissue February 2011
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 $2,134.00
Bone - Milled >50gr (100cc equivalent)
PBT10 Perth Bone and Tissue Bank $3,135.00
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 $2,734.00
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 $2,284.00
Cortical Strut >20cm
PBT48 Perth Bone and Tissue Bank $2,451.00
Cortical Struts 10-15cm
PBT06 Perth Bone and Tissue Bank $1,914.00
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 $825.00
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 $2,050.00
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 $2,217.00
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 $1,606.00
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 $3,354.00
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 $5,683.00
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 $3,354.00
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 $2,577.00
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 $1,422.00
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 $2,841.00
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 $5,228.00
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 $1,134.00
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 $1,031.00
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 $1,134.00
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 $2,788.00
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 $1,856.00
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 $1,031.00
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 $2,564.00
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
Page 12 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
Tendon - Peroneus Longus
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 $2,124.00
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
Page 13 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
MVS11 Institute of Medical & Veterinary Science T/A South Australian Tissue Bank $2,290.00
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 $3,979.00
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
Page 14 of 15
ORTHOPAEDIC
Billing Code Facility Minimum Benefit Maximum Benefit
NBB66 New South Wales Bone Bank $1,208.00
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 February 2011
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