Untitled document
Health Insurance (Section 3C Diagnostic Imaging Services—Multiparametric MRI of the prostate) Determination 2018
I, CELIA STREET, delegate of the Minister for Health, make this Determination under subsection 3C(1) of the Health Insurance Act 1973.
Dated 12 June 2018
Celia Street
Assistant Secretary
Diagnostic Imaging and Pathology Branch
Medical Benefits Division
Department of Health
Contents
1. Name of Determination
2. Commencement
3. Authority
4. Definitions
5. Treatment of relevant services
6. Application of items
7. Limitation of items
Schedule – relevant services
Name of Determination
This Determination is the Health Insurance (Section 3C Diagnostic Imaging Services—Multiparametric MRI of the prostate) Determination 2018.
Commencement
This Determination commences on 1 July 2018.
Authority
This Determination is made under subsection 3C(1) of the Health Insurance Act 1973.
Definitions
In this Determination:
Act means the Health Insurance Act 1973.
clinical concern means a clinical decision that the prostate cancer has progressed, and includes prostate specific antigen progression.
eligible equipment has the meaning given by clause 2.5.5 of the diagnostic imaging services table.
eligible provider has the meaning given by clause 2.5.4 of the diagnostic imaging services table.
partial eligible equipment has the meaning given by clause 2.5.6 of the diagnostic imaging services table.
relevant family history means, for any particular patient, a first degree relative with prostate cancer, or suspected of carrying a BRCA 1 or BRCA 2 mutation.
relevant provisions means all provisions, of the Act and regulations made under the Act, and the National Health Act 1953 and regulations made under that Act, relating to medical services, professional services or items.
relevant service means a health service, as defined in subsection 3C(8) of the Act, that is specified in the Schedule.
scan means a minimum of 3 sequences.
Schedule means the Schedule to this Determination.
Note: The following terms are defined in subsection 3(1) of the Act:
·clinically relevant service
·diagnostic imaging services table
·item
·professional service
·specialist
(2) Unless the contrary intention appears, a reference in this Determination to a provision of the Act or the National Health Act 1953 or regulations made under the Act or under the National Health Act 1953 as applied, adopted or incorporated in relation to specifying a matter is a reference to those provisions as in force from time to time and any other reference to provisions of an Act or regulations is a reference to those provisions as in force from time to time.
Treatment of relevant services
For subsection 3C(1) of the Act a relevant service, provided in accordance with this Determination and as a clinically relevant service, is to be treated, for the relevant provisions, as if:
(a)it were both a professional service and a diagnostic imaging service; and
(b)there were an item in the diagnostic imaging services table that:
(i)related to the service; and
(ii)specified for the service a fee in relation to each State, being the fee specified in the Schedule in relation to the service.
Application of items
For any particular patient, items in the Schedule apply to a service performed:
(a)at the request of a specialist in the speciality of urology, radiation oncology, or medical oncology; and
(b)in a permissible circumstance; and
(c)using:
(i)eligible equipment; or
(ii)partial eligible equipment.
For the purposes of paragraph 6(1)(a), a request must be:
(a)made in writing; and
(b)identify the clinical indications for the service.
For the purposes of paragraph 6(1)(b), a service is performed in a permissible circumstance only if it is:
(a) both:
(i)performed under the supervision of an eligible provider who is available to monitor and influence the conduct and diagnostic quality of the examination, including, if necessary, by personal attendance on the patient; and
(ii)reported by an eligible provider; or
(b)performed in an emergency; or
(c)performed because of medical necessity, in a remote location.
Limitation of items
For any particular patient, items 63541 and 63542 are applicable not more than once in a 12 month period.
For any particular patient, items 63543 and 63544 are applicable:
(a)at the time of diagnosis of prostate cancer; and
(b)12 months following diagnosis; and
(c)every third year thereafter; or
(d)at any time if there is clinical concern from the specialist requesting the service in paragraph 6(1)(a).
Items 63543 and 63544 are not applicable for the purposes of treatment planning or for monitoring after treatment of prostate cancer.
Schedule – relevant services
| Category 5 – Diagnostic Imaging Services | ||
| Group I5 – Magnetic Resonance Imaging | ||
| Sub Group 19 – Scan of Body – For Specified Conditions | ||
| Item | Service | Fee ($) |
| 63541 | Multiparametric Magnetic Resonance Imaging scan of the prostate for the detection of cancer, if the request for the scan identifies: a) that the patient is suspected of developing prostate cancer, due to one of the following: (i) a digital rectal examination which is suspicious for prostate cancer; or (ii) in a person under 70 years, at least two prostate specific antigen (PSA) tests performed within an interval of 1- 3 months are greater than 3.0 ng/ml, and the free/total PSA ratio is less than 25% or the repeat PSA exceeds 5.5 ng/ml; or (iii) in a person under 70 years, whose risk of developing prostate cancer based on relevant family history is at least double the average risk, at least two PSA tests performed within an interval of 1- 3 months are greater than 2.0 ng/ml, and the free/total PSA ratio is less than 25%; or (iv) in a person 70 years or older, at least two PSA tests performed within an interval of 1- 3 months are greater than 5.5ng/ml and the free/total PSA ratio is less than 25%. b) using a standardised image acquisition protocol involving T2 Weighted Imaging, Diffusion Weighted Imaging, and Dynamic Contrast Enhancement (unless contraindicated) (R) (K) (Anaes) | 450.00 |
| 63542 | Multiparametric Magnetic Resonance Imaging scan of the prostate for the detection of cancer, if the request for the scan identifies: a) that the patient is suspected of developing prostate cancer, due to one of the following: (i) a digital rectal examination DRE which is suspicious for prostate cancer; or (ii) in a person under 70 years, at least two prostate specific antigen (PSA) tests performed within an interval of 1- 3 months are greater than 3.0 ng/ml, and the free/total PSA ratio is less than 25% or the repeat PSA exceeds 5.5 ng/ml; or (iii) in a person under 70 years, whose risk of developing prostate cancer based on relevant family history is at least double the average risk, at least two PSA tests performed within an interval of 1- 3 months are greater than 2.0 ng/ml, and the free/total PSA ratio is less than 25%; or (iv) in a person 70 years or older, at least two PSA tests performed within an interval of 1- 3 months are greater than 5.5ng/ml and the free/total PSA ratio is less than 25%. b) using a standardised image acquisition protocol involving T2 Weighted Imaging, Diffusion Weighted Imaging, and Dynamic Contrast Enhancement (unless contraindicated) (R) (NK) (Anaes) | 225.00 |
| 63543 | Multiparametric Magnetic Resonance Imaging scan of the prostate for the assessment of cancer: a) if the request for the scan identifies: (i) the patient is under active surveillance following a confirmed diagnosis of prostate cancer by biopsy histopathology; and (ii) the patient is not planning or undergoing treatment for prostate cancer. b) using a standardised image acquisition protocol involving T2 Weighted Imaging, Diffusion Weighted Imaging, and Dynamic Contrast Enhancement (unless contraindicated) (R) (K) (Anaes) | 450.00 |
| 63544 | Multiparametric Magnetic Resonance Imaging scan of the prostate for the assessment of cancer: a) if the request for the scan identifies; (i) the patient is under active surveillance following a confirmed diagnosis of prostate cancer by biopsy histopathology; and (ii) the patient is not planning or undergoing treatment for prostate cancer. b) using a standardised image acquisition protocol involving T2 Weighted Imaging, Diffusion Weighted Imaging, and Dynamic Contrast Enhancement (unless contraindicated) (R) (NK) (Anaes) | 225.00 |
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