Private Health Insurance (Prostheses) Rules 2009 (No. 2)

As amended

Made under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007. 

This compilation was prepared on 10 December 2009 taking into account amendments up to the Private Health Insurance (Prostheses) Amendment Rules 2009 (No 3).

Prepared by the Department of Health and Ageing, Canberra.

Contents

Part 1 Preliminary 

1. Name of Rules 

2. Commencement 

3. Revocation 

4. Definitions 

Part 2 Benefit requirements 

5. Listing of, and benefits, for prostheses 

6. Benefits for prostheses provided as part of hospital treatment 

7. Benefits for prostheses provided as part of hospital-substitute treatment 

8. Timing of applications to have a prosthesis listed 

9. Minister may have regard to recommendations and advice 

Notes 

Schedule 

Part 1 Preliminary

1.                      Name of Rules

These Rules are the Private Health Insurance (Prostheses) Rules 2009 (No. 2).

2.                      Commencement

These Rules commence on 15 August 2009.

3.                      Revocation

These Rules revoke the Private Health Insurance (Prostheses) Rules 2009 (No. 1) (as amended by the Private Health Insurance (Prostheses) Amendment Rules 2009 (No.1).

4.                      Definitions

Note: Terms used in these Rules have the same meaning as in the Act―see section 13 of the Legislative Instruments Act 2003.  These terms include:

 complying health insurance policy
hospital-substitute treatment
hospital treatment
medicare benefit

In these rules:

accredited podiatrist has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

Act means the Private Health Insurance Act 2007.

gap permitted prosthesis means a prosthesis listed in the Schedule where an amount is specified for that prosthesis in the column under the heading 'Minimum Benefit' and a different amount is specified in the column under the heading 'Maximum Benefit'.

no gap prosthesis means a prosthesis listed in the Schedule where an amount is specified for that prosthesis in the column under the heading 'Minimum Benefit' and no amount is specified in the column under the heading 'Maximum Benefit'.

private hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a private hospital.

Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.

professional service has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

public hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a public hospital.

Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.

Schedule means the Schedule in these Rules.
 

Part 2 Benefit requirements

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 prostheses (listed prostheses) the Minister has listed under subsection 72-10 (5) of the Act and section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007; and

Note: Section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the listing of a prosthesis that was a no gap prosthesis or a gap permitted prosthesis for the purposes of the National Health Act 1953 immediately before the commencement of the Act.

(b)                    rule 6 sets out the method for working out the minimum benefit and maximum benefit for hospital treatment, covered under a complying private health insurance policy, that is the provision of a listed prosthesis in circumstances where:

(i)                     a medicare benefit is payable in respect of the professional service associated with the provision of the prosthesis; or

(ii)                   the provision of the prosthesis is associated with podiatric treatment by an accredited podiatrist; and

(c)                    rule 7 sets out the method for working out the minimum benefit and maximum benefit for hospital-substitute treatment, covered under a complying private health insurance policy, that is the provision of a listed prosthesis in circumstances where a medicare benefit is payable in respect of the professional service associated with the provision of the prosthesis.

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 in the circumstances mentioned in paragraph 5(b), the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in the Schedule under the heading ‘Minimum Benefit’.

(2)        For a gap permitted prosthesis provided as part of an episode of hospital treatment by a private hospital in the circumstances mentioned in paragraph 5(b):

(a)                    the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and

(b)                    the maximum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Maximum Benefit’.

(3)        For a no gap prosthesis provided as part of an episode of hospital treatment by a public hospital in the circumstances mentioned in paragraph 5(b):

(a)                    the minimum benefit is the lesser of the following amounts:

(i)                     the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or

(ii)                   the amount of the insured person’s liability to the public hospital for that prosthesis; and

(b)                    the maximum benefit is the amount for that prosthesis listed in the column under the heading 'Minimum Benefit'.

(4)        For a gap permitted prosthesis provided as part of an episode of hospital treatment by a public hospital in the circumstances mentioned in paragraph 5(b):

(a)                    the minimum benefit is the lesser of the following amounts:

(i)                     the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or

(ii)                   the amount of the insured person’s liability to the public hospital for that prosthesis; and

(b)                    the maximum benefit is the amount for that prosthesis listed in the column under the heading ‘Maximum Benefit’ in the Schedule.

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 in the circumstances mentioned in paragraph 5(c) the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in the Schedule under the heading ‘Minimum Benefit’.

(2)        For a gap permitted prosthesis provided as part of an episode of hospital-substitute treatment in the circumstances mentioned in paragraph 5(c):

(a)                    the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and

(b)                    the maximum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Maximum Benefit’.

Note: Private health insurers cannot cover, as part of hospital-substitute treatment, a service for which medicare benefit is payable unless the service is specified in the Private Health Insurance (Health Insurance Business) Rules 2007―see paragraph 121-10 (3) (a) of the Act.

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 prosthesis will be listed in the Schedule the next time the Minister makes or varies the Rules.

Note 1:  Under subsection 72-10 (5) of the Act the Minister must list the kind of prosthesis, set out the minimum benefit and, if the Minister considers it appropriate, the maximum benefit for the prosthesis in these Rules on the next occasion that the Minister makes or varies the Rules after he or she grants an application and the applicant has paid to the Commonwealth any initial listing fee within 14 days of being informed of the Minister's decision to grant the application.

Note 2: Under subsection 72-15 (3) of the Act, the Minister may remove a prosthesis from the list in the Rules if the applicant fails to pay an ongoing listing fee.

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 and Devices Committee.

(2)        In setting the minimum and the maximum (if any) amounts for a prosthesis, the Minister may have regard to the amounts as negotiated between the Prostheses and Devices Negotiating Group and the applicant.

Notes

The Private Health Insurance (Prostheses) Rules 2009 (No.2) as shown in this compilation are amended as indicated in the tables below.

Table of Instruments

Table of Amendments

Schedule

Part A - Prostheses List August 2009

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

Cardiac - Other

 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 1- Cardiothoracic Mechanical Valves

 Group 1c - Bi-Leaflet, rotatable

 Advanced Biomedical Pty Ltd

AB002 ATS medical open pivot heart valve  Pyrolythic Carbon, Double Velour  16-33mm $6,000.00

 model 500FA standard flexi-cuff aortic  Polyester, Titanium

 valve series, ATS medical open pivot

 heart valve model 500DM standard

 flexi-cuff mitral valve series

AB064 ATS medical open pivot heart valve  Pyrolythic Carbon, Double Velour  16-33mm $6,000.00

 model 501DA advanced performance  Polyester, Titanium

 (AP) aortic valve series, ATS medical

 open pivot heart valve model 501DM

 advanced performance (AP) mitral valve

 Medtronic Australasia Pty Ltd

MC292 Advantage Heart Valve - Aortic Model  A7760 - Pyrolytic carbon, PET Diameter 19-31 mm $6,000.00

 A7760

MC324 Advantage Supra Aortic  Heart Valve Mechanical Heart Valve Pyrolite Carbon  Diameter (mm): 19 - 25 $6,000.00

 leaflets Pyrolite carbon ring

MC681 Advantage Mitral Mechanical Heart Valve 23mm-33mm $6,000.00

 Reid Healthcare

RH001 Aortic On-X Prosthetic Heart Valve  27-29mm, 19mm, 21mm,  $5,500.00

 Models ONXA-19; ONXA-21; ONXA- 23mm, 25mm, 25-33mm, 27-

 23; ONXA-25; ONXA-27/29; ONXM- 29mm, 31-33mm, 23mm,

 23; ONXM-25; ONXM-27/29;

 ONXM31/33; ONXMC25/33

Prostheses List by Category, Groups and Sponsor Page 1 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 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 -27mm, Rotatable 17 - 33mm

  Cuff Heart Valve; St Jude Medical

 Mechanical Heart Valve Masters Series

SJ039 Regent Prosthestic Heart Valves Standard Cuff - Model 17AGFN-751 -  Standard cuff - 17-23mm, Flex  $6,500.00

 23AGFN-751, Flex Cuff - Mode  cuff - 17-23mm

 17AGFN-756 - 23AGFN-756

SJ116 Regent Prosthestic Heart Valves Standard Cuff - Model 25AGFN-751 -  Standard cuff - 25-29mm, Flex  $6,000.00

 29AGFN-751, Flex Cuff - Mode  cuff - 25-29mm

 25AGFN-756 - 29AGFN-756

 Group 1e - Tilting Disc, rotatable

 Medtronic Australasia Pty Ltd

MC013 Medtronic Hall Heart Valve Aortic Model A7700/M7700 Titanium. Pyrolite.  A7700 - Diameter 20-31mm,  $5,100.00 $5,625.00

  A7700, Medtronic Hall Heart Valve  Dacron, A7700EZ/M7700EZ Titanium.  M7700 - Diameter 23-33mm,

 Mitral Model M7700, Hall Easy Fit  A7700EZ - Diameter 19-29mm,

 Aortic Heart Valve Model A7700, Hall  M7700EZ - Diameter 23-31mm

 Easy Fit Mitral Heart Valve Model M7700

Group 1: Single Chamber ICD's

 Generation 2

 Biotronik Australia Pty Ltd

BT054 Lexos VR Single chamber ICD, Rate responsive  One size only. $36,400.00

 Generation 3

 Biotronik Australia Pty Ltd

BT075 Lumos VR-T Single Chamber ICD with home  one size only $40,560.00

 monitoring and IEGM online

BT087 Lumax 300 VR-T ICD-VR with bidirectional Home  One Size Only $40,560.00

 Monitoring. Single chamber

Prostheses List by Category, Groups and Sponsor Page 2 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Guidant Australia Pty Ltd

GU110 Ventak Prizm II VR Model 1860, titanium, single chamber,  One size only $40,560.00

 adaptive rate

GU133 Vitality VR Model 1870 This device acts to defibrillate the heart  Model 1870 Vitality VR Single  $40,560.00

 chambers when the patient enters into an  Chamber Rate Responsive

 arrhythmia or uses shocks or anti tachy  Pacemaker/Defibrillator

 pacing to revert Ventricular Tachycardia

 (VT) or Ventricular Fibrillation (VF).

 While also acting as a single chamber

GU148 Vitality 2 EL VR - Model T177 Implantable Cardiac Defibrillator 35cc 90g $40,560.00

GU151 Vitality 2 VR - Model T 175 Implantable cardiac defibrillator 30cc; 82g $40,560.00

 Sorin Group

SA139 OVATIO VR 6250 Titanium, single chamber, sterile, VR  29cc $40,560.00

 6250, 34J

 St. Jude Medical Australia Pty Ltd

SJ048 Epic Plus VR Model V-196 Implantable  Single Chamber sensing and bradycardia  32cc $40,560.00

 Cardioverter Defibrillator pacing

SJ093 Epic II VR V-158 Implantable Cardiac  Single Chamber Cardioverter Defibrillator 34cc, 70g $40,560.00

 Defibrillator

 A

 Biotronik Australia Pty Ltd

BT090 Lumax 340 VR-T ICD-VR 34 J with bidirectional Home  One size only $42,640.00

 Monitoring. Single chamber

BT098 Lumax 340 VR-T XL ICD-VR with 40 J output, bidirectional  One Size Only $42,640.00

 Home Monitoring and High Longevity

BT100 LUMAX 540 VR-T High Energy, Single-Chamber ICD  Diamensions: 66*55*13 mm  $42,640.00

 (Implantable Cardiac Defibrillator) with  Volume/Weight : 37.2cc/92g

 Advanced Patient Management Via unique

  Home Monitoring Technology

 incorporatin Automatic Threshold

 Monitoring and Extended Longevity.

 Boston Scientific Australia Pty Ltd

BS132 Teligen 100 HE VR 4-SITE High energy single chamber ICD with 4- 30.5cc, 9.9mm $43,390.00 $44,640.00

 SITE inline RV connector (GDT-LLHH)

BS136 TELIGEN 100 HE VR DF-1/IS-1 High energy single chamber ICD with  31.5cc, 9.9mm $42,640.00

 DF-1/IS-1 connector

Prostheses List by Category, Groups and Sponsor Page 3 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Medtronic Australasia Pty Ltd

MC722 Virtuoso VR ModelImplantable Cardioverter  37cc, 68g $42,640.00

 Defibrillator, Single Chamber

MC813 Secura VR Fully Automatic, Wireless Implantable  37cc $42,640.00 $45,760.00

 cardioverter defibrillator with high energy

  capability and therapies for ventricular

 tachyarrhythmia

 St. Jude Medical Australia Pty Ltd

SJ012 Atlas VR Model V-199 Single chamber implantable cardioverter  36cc $42,588.00

 defibrillator with rate response

SJ065 Atlas + VR Model V-193 ICD Single chamber implantable cardio-verter  38cc, 77g $42,640.00

 defibrillator

SJ066 Atlas + VR - C Model V-193C ICD Single chamber implantable cardio-verter  38cc, 77g $42,640.00

 defibrillator

SJ114 Atlas II VR-168 Single chamber cardioverter defibrillator 38cc, 77g $42,640.00

SJ121 Current VR 1107-36 Single Chamber Cardioverter Defibrillator 38cc 76g $42,640.00

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

 with RF Telemetry and ST Segment

 Monitoring

SJ147 Current Accel VR RF CD1215-36 Single Chamber Cardioverter Defibrillator  79g, 38cc $42,640.00

 with RF Telemetry

SJ154 AnalyST Accel VR CD1219-36 Single Chamber Cardioverter Defibrillator  79g, 41cc $42,640.00

 with RF Telemetry and ST Segment

 Monitoring

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 4 of 871

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-

Group 12: Coronary Stents

 Sub-Group 1: 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

 Boston Scientific Australia Pty Ltd

BS074 Taxus on Express2 Coronary Stent  balloon expandable stent with conformal  Length 8 - 32mm; Diameter  $3,450.00

 System Models 38001-0822 to 0840;  polymer/drug matrix coating, pre- 2.25 - 5.0mm

 38001-1222 to 1250; 38001-1622 to  mounted on high pressure monorail

 1650;38001-2022 to 2050; 38001-

 2422 to 2450; 38001-2827 to 2850;

BS099 Taxus Liberte Paclitaxel-Eluting  316L Stainless Steel Stent with Translute  2.0mm-5.0mm & 8.0mm-38mm $3,450.00

 Coronary Stent System Polymer and Paclitaxel

 Johnson & Johnson Medical Pty Ltd

JJ302 CYPHER Sirolimus-Eluting Stent &  Stainless steel coronary stent with  Diameter 2.25 - 5.0mm, length  $3,450.00

 Delivery System Model  CRS - 23300,  Rapamycin (an immunosuppressive and  8-33mm

 08225, 08250, 08275, 08300, 28225,  antiproliferative drug) bound to the stent

 28250, 28275, 28300, 33225, 33250,

 33275, 33300, 13225, 13250, 13275,

 18225, 18250, 18275, 18300, 23225,

 23250, 23275, 23350, 23400, 08350,

 08400, 2835

Prostheses List by Category, Groups and Sponsor Page 5 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

JJ481 CYPHER SELECT Sirolimus-Eluting  Stainless steel coronary stent with  Diameter 2.25 - 5.0mm, length 8 $3,450.00

 Stent & Delivery System Sirolimus (an immunosuppressive and   - 33mm

 anti-proliferative drug) bound to the stent

 by a polymer. Model CRA-23300, 08225,

  08250, 08275, 08300, 28225, 28250,

 28275, 28300, 33225, 33250, 33275,

JJ587 CYPHER Select Plus Sirolimus Eluting  Stainless steel coronary stent with  Diameter 2.25 - 5.00mm,  $3,450.00

 Coronary Stent Sirolimus bound to the stent by a polymer Length 8 - 33mm

 Medtronic Australasia Pty Ltd

MC732 Endeavour Drug Eluting Coronary Stent  Cobalt Alloy, ABT - 578 Diameter: 2.25mm-4.5mm;  $3,450.00

 System Length: 8.00mm-38.0mm

MC769 Endeavor Sprint Drug Eluting Stent  Cobals Alloym ABT - 578 Diameter: 2.25mm-4.0mm;  $3,450.00

 Length: 8.0mm-30.0mm

MC816 Endeavor Resolute Drug Eluting  Cobalt Alloy, ABT - 578, BioLinx  Diameter:2.25mm-4.0mm;  $3,450.00

 Coronary Stent System Length: 8.00mm-30.0mm

 Sub-Group 2: General purpose bare metal stents

 Abbott Australasia Pty Ltd

AY025 Stents ACS Multilink Coronary Stent; ACS  1.5mm - 8.0mm $1,248.00

 Megalink Peripheral Stent; ACS RX

 Herculink Peripheral Stent. Stainless steel

AY026 Multilink Coronary Stent System Stainless Steel Length 1.5mm - 8.0mm $1,248.00

AY027 Multilink Coronary Stent System -  316L Stainless steel stent Length 1.5 - 8.0mm $2,496.00

AY028 Multilink Coronary Stent System -  Cobalt chrome stent Length 1.5 - 8.0mm $1,248.00

 Atrium Australia - Pacific Rim Pty Limited

AC022 Flyer RX Coronary Stent System Stainless Steel Coronary Stent Dia 2-5mm, Length 6-40mm $780.00

AC030 Cinatra Cobalt Chromium Coronary  The Cinatra Cobalt Chromium Coronary  Diameter range: 2.5mm -  $1,248.00 $1,372.00

 Stent System Stent System consists of a balloon  3.5mm.  Length range: 8mm -

 expandable Cobalt Chromium stent

 premounted on a rapid exchange system

 Bio Excel Australia Pty Ltd

BE001 Gazelle Coronary Stent Stainless Steel Diam 2.25-4.0mm  Length 8- $600.00

 Biotronik Australia Pty Ltd

BT058 Lekton Motion Coated flexible stent, Balloon mounted Diameter 2.5mm to 4mm,  $1,248.00

 Length 8 - 30mm

Prostheses List by Category, Groups and Sponsor Page 6 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

BT082 PRO-Kinetic Cobalth Chromium coronary stent system 8-40mm length 2-5mm diameter $1,200.00

BT107 PRO-Kinetic Energy The PRO-Kinetic Energey stent is a  The PRO-Kinetic Energy stent is $1,248.00

 tubular, balloon-expandable stent sculpted  available in 66 different

  by laser from a single tube of L-605  diameter/length combinations.  It

 cobalt chromium (CoCr) alloy.  The stent  is available in lengths from

  consists of circular segments at each end 8mm to 40mm.  It is

  followed by a transition zone and  premounted on a delivery

 helicoidally arranged struts in the middle.  system which has nominal

  Each loop of the helix is connected to the balloon diameters between

  next loop by 3 longitudinal struts.  The

 stent surface is fully coated with a layer

 of amorphous hydrogen-rich silicon

 carbide (aSiC:H).  This material has

 semiconducting properties that efficiently

 prevent the electron transfer from

 fibrinogen to the metal surface in vitro. 

 Thereby the conversion from fibrinogen

 to fibrin and it's depoisition at the stent

 surface is reduced.  Additionally, aSiC:H -

  coated stents exhibit a lower adhesion

 and activation of blood platelets and

 leucocytes.  Finally, the release of

 potentially allergenic ions from a silicon

 carbide coated stent is substantially

 reduced in comparison to an uncoated

 metal stent3.  This coating is used on all

 Biotronik coronary stents producedso far

 Boston Scientific Australia Pty Ltd

BS069 Express 2/Liberte Coronary Stent  Consists of a balloon expandable stent,  Stent lengths: 8,12,16,20,24,28  $1,248.00

 pre-mounted on a Maverick 2 Monorail  & 32 mm Stent diameters: 2.25,

 delivery catheter. 2.5, 2.75, 3.0, 3.5, 4.0, 4.5 &

BS125 Promus Everolimus Coronary Stent  Cobalt chromium alloy stent coated with  2.25mm to 4.0mm diameter,  $3,450.00

 a blended polymer mixed with Everolimus. 8mm to 28mm length

 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.  Diameters: 

 exchange delivery catheter 2.25mm, 2.5mm, 2.75mm,

 3.0mm, 3.5mm, 4.0mm

IX002 Nile CroCo Intracoronary stent pre-mounted on two  Diameter main branch balloon:  $1,750.00

 rapid exchange delivery systems for  2.50 - 3.50mm.  Diameter side

 bifurcation lesions treatment branch balloon: 2.00 - 3.00mm

Prostheses List by Category, Groups and Sponsor Page 7 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Johnson & Johnson Medical Pty Ltd

JJ026 BX Velocity with Hepacoat System Balloon expandable, stainless steel,  . $1,220.00

 heparin coated

JJ200 BX Velocity Stent and Delivery System Stainless steel stent Diameter: 2.25-5.0 mm; Length  $1,220.00

 8 - 33 mm

JJ239 BX Sonic Stainless steel coronary stent mounted on Dia 2.25 - 4.0mm, lengths 8 -  $1,220.00

  a balloon delivery system

JJ670 Presillion CoCr Coronary Stent on RX  Cobalt Chromium, bare metal coronary  Stent Length (mm) x Stent  $1,248.00

 System Diameter (mm) 8 x 2.50, 2.75,

 3.0, 3.50, 4.0; 12 x 2.50, 2.75,

 3.0, 3.50, 4.0; 17 x 2.50, 2.75,

 3.0, 3.50, 4.0; 24 x 2.75, 3.0,

 3.50, 4.0; 33 x 2.75, 3.0, 3.50,

 4.0; 33 x 2.75, 3.0, 3.50, 4.0,

 20 x 2.50, 2.75, 3.0, 3.50, 4.0

 Medtronic Australasia Pty Ltd

MC197 Medtronic AVE S660 Coronary Stents,  Stainless Steel S660 Coronary Stent - Diameter $1,144.00

 S670 Coronary Stents, S7 Coronary   (2.5mm-2.75mm), Length

 Stents, BeStent2, (9mm-24mm); S670 & S7

 Coronary Stent - Diameter

 (3mm-4mm), Length (9mm-

 30mm); BeStent2 - Diameter

 (2.5mm-4mm), Length (9mm-

MC329 Medtronic Driver, Micro Driver  Cobalt Alloy Driver Stent: diameter (2.25 -  $1,248.00

 Coronary Stent System 4.5mm), length (8-30mm);

 Micro-Driver Stent: diameter

 (2.25 - 2.75mm), length (8 -

 OrbusNeich  Medical Pty Ltd

NM003 R Stent Evolution 2 Coronary Delivery  316LVM Stainless Steel Balloon  Lengths - 9-33mm; Diameters -  $1,144.00

 System Expandable Stent (Tubular) 2.5-4.0mm

NM004 Blazer Coronary Stent Delivery System L605 Cobalt Chromium alloy balloon  Expanded Stent Diameter 2.5 to  $1,248.00

 expandable vascular prosthesis 4.0mm, Stent Length 9 to 33mm

 Pacing Importers Pty Ltd - Life Systems

PI001 Excimer Laser Stent Polyester Fibre optic catheter 2.5 and 2.2mm $6,800.00

PI002 Excimer Laser Stent Polyester Fibre optic fibre catheter 0.457mm, 0.9mm, 1.4mm,  $6,800.00

 1.7mm and 2.0mm

PI003 Med-X-Flexy Stent Tubular Stent, Stainless steel 316L, Gold  Dia 5 - 9mm  length: 20 -  $780.00

 markers

Prostheses List by Category, Groups and Sponsor Page 8 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Terumo Corporation Australia

TU001 Tsunami Gold Stainless Steel mounted on balloon  Diameter 2.0mm - 4.0mm,  $1,248.00

 Length 8mm - 30mm length

 a,b,c,d

 Abbott Australasia Pty Ltd

AY012 JoStent Coronary Stent Graft Stainless Steel/PTFE 9 - 26 mm x 2.5 - 5 mm $3,222.00

Group 13: Special Purpose Percutaneous Cardiovascular Devices

 Sub-Group 1: Intracardiac Defect Occluders

 a

 Medtel Australia Pty Ltd

ME065 Amplatzer Duct Occluder Nitinol Wire Mesh 5 - 24mm $10,200.00

ME066 Amplatzer Septal Occluder Nitinol Wire Mesh 4mm - 40mm $10,200.00

ME067 Amplatzer Muscular VSD Occluder Nitinol Wire Mesh 4 - 24mm $10,200.00

ME068 Amplatzer PFO Occluder Nitinol Wire Mesh 25mm & 35mm $10,200.00

ME074 Amplatzer Membranous VSD Occluder Nitinol wire mesh, double disc occluder  4-24mm, Length 7-10mm $10,200.00

 and delivery system

 St. Jude Medical Australia Pty Ltd

SJ091 Premere PFO Closure System Percutaneous, transcatheter, self- Left Atrial Anchor diameter  $10,036.00

 expanding, dual anchor, occlusion device 20mm, 25mm and 30mm

Prostheses List by Category, Groups and Sponsor Page 9 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 W L Gore & Associates

GT223 Helex 1.5 Septal Occluder The GORE HELEX Septal Occluder  Diameters: 15, 20, 25, 30 and  $10,200.00

 consists of an implantable endoprosthesis  35mm

 and a catheter delivery system.  The

 Occluder is comprised of a nickel-

 titanium (Nitinol) wire frame covered

 with expanded polytetrafluoroethylene

 (ePTFE).  The ePTFE is treated with a

 hydrophilic coating to facilitate

 echocardiographic imaging of the

 Occluder during implantation.  When fully

  deployed, the Occluder assumes a double

  disc configuration that bridges the septal

 defect to precent shunting of blood

 between the right and left atria (Figure 1a,

  b).  The delivery system consists of

 three distal co-axial components

 transitioning to a parallel component

 arrangement at the proximal Y-arm hub: a

  10 Fr Green Delivery Catheter, a Gray

 Control Catheter and a Tan Mandrel

 (Figure 2).  The proximal end of the

 Conotrol Catheter exits the Y-arm hub

 and is terminated by a Red Retrieval Cord

  Cap.  The proximal end of the Mandrel

 exits the side port of the Y-arm hub and

 is terminated by a Clear Leur.  The

 Control Catheter is equipped with a

 retrieval cord if Occluder repositioning or

  retrieval is deemed necessary (Figure 2).

 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,

Prostheses List by Category, Groups and Sponsor Page 10 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

DW002 Nit-Occlud PDA Occlusion System  Nitinol spiral coil and delivery system for  Distal x Proximal Coil Diameter:  $1,650.00

 (Medium) transcatheter occlusion of PDA 7 x 6mm, 9 x 6mm, 11 x 6mm,

 12 x 6mm, 14 x 6mm;

 Introducer Sheath:  5F; Length

 Introducer: 85cm, 105cm; Coil

 Length configurated +-0.5mm:

Group 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

 St. Jude Medical Australia Pty Ltd

SJ141 SJM Epic Supra Valve triple composite Bioprosthetic heart valve  Tissue Annulus Diameter - 19- $4,445.00

 for supra-annular placement in the aortic  23mm

 Total Height - 14-16mm

SJ156 SJM Epic Valve Triple composite bioprosthetic heart valve Aortic valve 21-29mm tissue  $4,445.00

 annulus diameter

 14-20 total height

 Mitral Valves 25-33mm tissue

 annulus diameter

 15-20mm total height

 B (Bovine), E (Equine), P (Porcine)

 Edwards Lifesciences Pty Ltd

EL030 CE Supra Annular Aortic Valve Model  Carpentier-Edwards SAV Bioprosthesis.  19mm-33mm $4,445.00

 2650 Carpentier-Edwards S.A.V  Composition: Porcine Valve; Elgiloy

 Bioprosthesis Model 6650 Mitral Valve Alloy; Silicone Rubber,

 Medtronic Australasia Pty Ltd

MC701 Mosaic Cinch, Aortic, Mitral Models 305cxx, 310cxx 19mm - 35mm $4,445.00 $5,345.00

MC771 Mosaic Ultra Small Aortic Root Bioprosthesis 19mm-29mm $4,445.00 $5,650.00

Prostheses List by Category, Groups and Sponsor Page 11 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 P (Porcine)

 St. Jude Medical Australia Pty Ltd

SJ069 St Jude Medical Biocor Porcine  St Jude Medical Biocor Porcine  Aortic Valves - Tissue Annulus  $4,445.00

 Prosthetic Heart Valve Prosthetic Heart Valve is manufactured  Diameter - 21-29mm,  Implant

 from selected procine aortic valve cusps  Height - 11-15c;  Mitral Valves -

 that have been cross-linked with a   Tissue Annulus Diameter - 25-

 35mm, Implant Height - 8-

SJ136 SJM Biocor Heart Valve Stented Porcine tissue valve Aortic Valves - Tissue Annulus  $4,445.00

 Diameter - 21 - 29mm             

                  Mitral Valves -

 Tissue Annulus Diameter - 25-

 35mm

 Group 2b - Stented, pericardial

 Edwards Lifesciences Pty Ltd

EL056 Magna Mitral Carpentier-Edwards PERIMOUNT  25, 27, 29, 31 and 33mm $5,000.00 $5,690.00

 Magna Mitral Bioprosthesis, Model

 Sorin Group

SA130 Mitroflow Pericardial Bioprosthesis 19-27mm $5,000.00

 (p)  Pericardial

 Edwards Lifesciences Pty Ltd

EL058 Magna Ease Carpentier - Edwards PERIMOUNT  19, 21, 23, 25, 27 and 29mm $5,000.00 $6,100.00

 Magna Ease Bioprosthesis, Model

 B (Bovine), E (Equine), P (Porcine)

 Edwards Lifesciences Pty Ltd

EL031 Carpentier-Edwards Perimount  Carpentier-Edwards Pericardial  Models 2900/6900 19-33mm,  $5,000.00

 Pericardial Bioprosthesis - Models  Bioprosthesis. Composition: Bovine  Model 6900P 25, 27, 29, 31,

 2900/6900  Carpentier-Edwards  Pericardium; Elgiloy Alloy; Silicone

 Perimount Plus Pericardial Bioprosthesis Rubber, Polytetrafluoroethylene

  Mitral - Model 6900P

Prostheses List by Category, Groups and Sponsor Page 12 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

EL039 Edwards Perimount Magna Model 3000 Carpentier-Edwards Perimount Magna  19MM Aortic Pericardial Tissue  $5,000.00 $5,690.00

 composition: Glutaraldehyde treated  Valve; 21MM Aortic Pericardial

 bovine pericardium/elgiloy wireform  Tissue Valve; 23MM Aortic

 stent/polyester band/silicone rubber  Pericardial Tissue Valve; 25MM

 suture ring/polytetrafluoroethylene  Aortic Pericardial Tissue Valve;

 cloth/polyester cloth. 27MM Aortic Pericardial Tissue

 Valve; 29MM Aortic Pericardial

 Tissue Valve

 Group 2c - Non-Stented

 Medtronic Australasia Pty Ltd

MC015 Freestyle bioprosthesis Models 995xx, 995MSxx 19 - 35mm $5,110.00 $5,350.00

 St. Jude Medical Australia Pty Ltd

SJ038 St Jude Medical Toronto SPV Valve  Tissue Heart Valves, Bioimplant TSPV: 21 - 29mm, Bioimplant  $4,900.00

 Model SPA-101, St Jude Medical  Aortic: 21-27mm, Bioimplant

 Bioimplant Heart Valve Mitral: 27-32mm

 Equine

 Advanced Biomedical Pty Ltd

AB070 ATS 3f Aortic Bioprosthesis (EQUINE) Model 1000 - EQUINE Pericardium  19 - 29 mm $5,000.00

 Bioprostheseis (non stented)

Group 2: Dual Chamber ICD's

 Generation 2

 A

 Guidant Australia Pty Ltd

GU107 Ventak Prizm HE DR Model 1853 & Model 1858, titanium, dual One size only $40,560.00

  chamber, adaptive rate

 Generation 3

 Biotronik Australia Pty Ltd

BT076 Lumos DR-T Dual Chamber ICD with home monitoring one size only $43,680.00

BT091 Lumax 300 DR-T ICD-DR with bidirectional Home  One size only $43,680.00

 Guidant Australia Pty Ltd

GU111 Ventak Prizm II DR Model 1861, titanium, dual chamber,  One size only $43,680.00

 adaptive rate

Prostheses List by Category, Groups and Sponsor Page 13 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

GU132 Vitality DR Model 1871 This device acts to defibrillate the heart  Model 1871 Vitality DR Dual  $43,680.00

 chambers when the patient enters into an  Chamber Rate Responsive

 arrhythmia or uses shocks or anti tachy  Pacemaker/Defibrillator

 pacing to revert Ventricular Tachycardia

 (VT) or Ventricular Fibrillation (VF).

 While also acting as a dual chamber

GU149 Vitality 2 DR - Model T165 Implantable Cardiac Defibrillator 30cc ; 82g $43,680.00

GU150 Vitality 2 EL DR - Model T167 Implantable cardiac Defibrillator 35cc ; 90g $43,680.00

 Sorin Group

SA140 OVATIO DR 6550 Titanium dual chamber ICD, 29 cc 29cc $43,680.00

 St. Jude Medical Australia Pty Ltd

SJ049 Epic Plus DR Model V-236 Implantable  Dual Chamber sensing, bradycardia  33cc $43,680.00

 Cardioverter Defibrillator pacing with atrial fibrillation suppression

SJ070 Epic + DR Model V-233 ICD Dual Chamber Implantable Cardio-verter  33cc 70g $43,680.00

 Defibrillator

SJ071 Epic + DR Model V-239 ICD Dual chamber implantable cardio-verter  33cc 70g $43,680.00

 defibrillator

SJ092 Epic II + DR V-258 Epic II + DR V-258 Implantable  35cc, 72g $43,680.00

 Cardioverter Defibrillator

SJ101 Epic II DR V-255 Epic II DR V-255 Implantable  34cc, 72g $43,680.00

 Cardioverter Defibrillator

 A

 Biotronik Australia Pty Ltd

BT086 Lumax 340 DR-T ICD-DR 34 J with bidirectional Home  One Size Only $45,760.00

 Monitoring. Dual chamber

BT101 Lumax 540 DR-T High Energy, Dual-Chamber ICD  Diamensions: 66*55*13mm,  $45,760.00

 (Implantable Cardiac Defibrillator) with  Volume/Weight: 37.2cc/92g

 Advanced Patient Management Via unique

  Home Monitoring Technology

 incorporating Automatic Ventricular

 Boston Scientific Australia Pty Ltd

BS128 Confient RF HE Dual chamber, high energy implantable  44cc, 87.5g $45,760.00

 cardioverter defibrillator with wireless

 radio frequency capability

BS134 TELIGEN 100 HE DR 4-SITE High energy dual chamber ICD with 4  31.55cc, 9.9mm $46,510.00 $47,760.00

 SITE (GDT-LLH) inline RV connector

Prostheses List by Category, Groups and Sponsor Page 14 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

BS135 Teligen 100 DR DF-1/IS-1 High energy dual chamber ICD 31.5cc, 9.9mm $45,760.00

 St. Jude Medical Australia Pty Ltd

SJ011 Atlas DR Model V-240 Dual chamber implantable cardioverter  37cc $45,760.00

 defibrillator with rate response

SJ063 Atlas DR Model V-242 ICD Implantable Dual Chamber Cardio-verter  38cc/78g $45,760.00

 Defibrillator

SJ068 Atlas + DR Model V-243 ICD Implantable Dual Chamber Cardio-verter  38cc, 78g $45,760.00

 Defibrillator

SJ115 Atlas II+ DR V-268 Dual Chamber Cardioverter Defibrillator 39cc, 78g $45,760.00

SJ120 Current DR RF 2207 Dual Chamber Cardioverter Defibrillator  80g, 42cc $45,760.00

 with RF Telemetry

SJ123 Current DR 2107 Dual Chamber Cardio-verter Defibrillator 39cc 78g $45,760.00

SJ143 AnalyST Accel DR CD2219-36 Dual Chamber cardioverter defibrillator  80g, 42cc $45,760.00

 with RF telemetry and ST Segment

SJ144 AnalyST DR Model CD2217-36 Dual Chamber cardioverter defibrillator  80g, 42cm $45,760.00

 with RF telemetry and ST Segment

SJ153 Current Accel DR RF CD2215-36 Dual Chamber Cardioverter Defibrillator  80g, 42cc $45,760.00

 with RF Telemetry

 A,c

 Medtronic Australasia Pty Ltd

MC814 Secura DR Fully Automatic, Wireless Implantable  37cc $45,760.00 $48,152.00

 cardioverter defibrillator with high energy

  capability and therapies for ventricular

 and atrial tachyarrhythmia

 c

 Guidant Australia Pty Ltd

GU137 Vitality AVT Dual chamber defibrillator, with atrial and One size only $45,760.00

  ventricular therapy

GU157 Vitality AVT - Model A155 Implantable cardiac defibrillator with both 30cc $45,760.00

  Atrial and Ventricular tachyarrhythmia

 therapy

 Medtronic Australasia Pty Ltd

MC721 Virtuoso DR ModelImplantable Cardioverter  37cc, 68g $45,760.00

 Defibrillator, Dual Chamber

Prostheses List by Category, Groups and Sponsor Page 15 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

Group 3 - Cardiothoracic Valve Conduits

 Group 3a - Mechanical Valve

 Advanced Biomedical Pty Ltd

AB001 ATS Medical open pivot aortic valved  Pyrolythic Carbon, Double Velour  21- 33mm $6,950.00

 graft model 502AG Polyester, Titanium

 Medtronic Australasia Pty Ltd

MC198 Medtronic Hall rotatable aortic valved  Titanium, pyrolite, dacron 20 - 33mm $6,950.00

 collagen impregnated conduit Model

 Sorin Group

SA128 CarboSeal Ascending Aortic Prosthesis,  Mechanical Conduit AP 21-33mm, CP 21 - 33mm $6,950.00

 sterile, CarboSeal Ascending Aortic

 Prosthesis with Handle Model AP21,

 Model AP23, Model AP25, Model AP27,

  Model AP29, Model AP31, Model

 AP33, Carboseal Valsalva

 St. Jude Medical Australia Pty Ltd

SJ036 St Jude Medical Coated Aortic Valved  Coated Aortic Valved Graft  21mm - 33mm $6,950.00

SJ104 SJM Masters Series Aortic Valved  St Jude Medical Mechanical Heart Valve  Annulus Diameter 19-29mm $6,950.00

 Prosthesis - VAVGJ sewn into the base of a woven polyester

 fibre graft which has been impregnated

 with bovine-derived gelatin

 Group 3b - Tissue Valve, stented porcine

 Medtronic Australasia Pty Ltd

MC012 Medtronic Hancock Valved Conduit  Porcine bioprosthesis, dacron 12, 14, 16, 18, 20, 22, 25,  $5,900.00 $6,800.00

 Model 100/150

Group 3: ICD's with CRT

 Generation 2

 Biotronik Australia Pty Ltd

BT088 Lumax 300 HF-T CRT-D with bidirectional Home  One size only $45,760.00

Prostheses List by Category, Groups and Sponsor Page 16 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Boston Scientific Australia Pty Ltd

BS112 Contak Renewal 4 RF CRT-D CRT-D with RF telemetry, IS-1  39cc, 82g $47,840.00

 connector H230

BS113 Contak Renewal 4 RF CRT-D CRT-D with RF telemetry, IS-1  39cc, 82g $47,840.00

 connector H235

BS129 LIVIAN CRT-D CRT-D (IS-1 and LV-1 connectors) 40cc, 79.5g, 14.5mm $47,840.00

 Guidant Australia Pty Ltd

GU134 Contak Renewal 2 This device acts to defibrillate the heart  One Size Only $45,760.00

 chambers when the patient enters into an

 arrhythmia or uses shocks or anti tachy

 pacing to revert Ventricular Tachycardia

 (VT) or Ventricular Fibrillation (VF).

 While also acting as a biventricular

GU147 Contak Renewal 4 CRT-D Model H190,  Implantable dual-chamber defibrillator One size only $45,760.00

 Model H195

 Sorin Group

SA138 OVATIO CRT-D 6750 Titanium, dual chamber ICD with CRT 30cc $45,760.00

 St. Jude Medical Australia Pty Ltd

SJ062 Epic HF Model V-339 Implantable  Cardioverter/defibrillator with dual  One size only $45,760.00

 Cardiac Defibrillator chamber (atrial and RV) sensing and

 bradycardia pacing with ventricular

SJ067 Epic + HF Model V-350 ICD Epic + HF V-350 ICD is a cardioverter  36cc / 73g $45,760.00

 defibrillator with dual chamber (atrial and

 RV) sensing and bradycardia pacing with

 ventricular resynchronisation therapy.

SJ098 Epic II+ HF V-357 Epic II + HF V-357 Cardiac  36cc, 74g $45,760.00

 Resynchronisation Therapy Defibrillator

 with V-V Timing programmability

SJ100 Epic II HF V-355 Epic II HF V-355 Cardiac  36cc,73g $45,760.00

 resynchronisation Therapy Defibrillator

 with V-V Timing programmability

SJ145 Promote Accel CD3215-30 Cardiac Resyncronisation Therapy  76g, 39cc $45,760.00

 Defibrillator with RF Telemetry

Prostheses List by Category, Groups and Sponsor Page 17 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 A

 Biotronik Australia Pty Ltd

BT089 Lumax 340 HF-T CRT-D 34 J with bidirectional Home  One Size Only $47,840.00

 Monitoring

BT102 Lumax 540 HF-T High Energy, Three Chamber ICD  Diamensions: 66*59*13 mm,  $47,840.00

 (Implantable Cardiac Defibrillator) with  Volume/Weight: 39.8cc/94g

 Advanced Patient Management Via unique

  Home Monitoring Technology

 incorporating Automatic RV/LV

 Threshold Monitoring and Extended

 Boston Scientific Australia Pty Ltd

BS114 Contak Renewal 4 RF CRT-D CRT-D with RF telemetry, IS-1  43cc, 90g $47,840.00

 connector H239 High Energy

BS130 LIVIAN CRT-D HE CRT_D RF High Energy (IS-1 and LV-1  44cc, 87.5g, 14.5mm $50,000.00

 connectors)

BS138 COGNIS 100 HE 4-SITE High Energy CRT-D with 4SITE (GDT- 32cc, 9.9mm $50,750.00 $52,000.00

 LLHH) inline RV connector

BS139 COGNIS 100 HE (DF-1/IS-1 & DF- High Energy CRT-D (DF-1/IS-1 & DF- 32.5cc, 9.9mm $50,000.00

 1/LV-1connectors)

 Guidant Australia Pty Ltd

GU144 Contak Renewal 4 HE CRT-D Model  Implantable dual-chamber defibrillator one size only $47,840.00

 H197, Model H199

 Medtronic Australasia Pty Ltd

MC720 Concerto CRT-D Implantable Cardioverter Defibrillator  38cc $50,000.00

 with Cardiac Resynchronisation Therapy

 St. Jude Medical Australia Pty Ltd

SJ064 Atlas + HF Model V - 341 ICD -  Atlas + HF ICD is a cardioverter  40cc/81g $47,840.00

 Defibrillator, Implantable, automatic,  defibrillator with dual chamber (atrial and

 dual-chamber RV) sensing and bradycardia Pacing with

 ventricular resynchronisation therapy.

SJ109 Atlas II+ HF V-367 Cardiac Resynchronisation Therapy  41cc, 79g $47,840.00

 Defibrillator with V-V Timing

 Programmability

SJ117 Promote CRT-D 3107 Cardiac Resynchronisation Therapy  41cc, 80g $47,840.00

 Defibrillator

Prostheses List by Category, Groups and Sponsor Page 18 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

SJ128 Promote RF CRT-D 3213 Cardiac Resynchronisation Therapy  43cc, 82g $47,840.00

 Defibrillator with RF Telemetry

 c

 Guidant Australia Pty Ltd

GU154 Contak Renewal 4 AVT CRT -D -  Implantable Cardioverter Defibrillator  37cc; 89g $50,960.00

 Model M170 and M175 with Cardiac Resynchronisation Therapy

GU155 Contak Renewal 4 AVT HE CRT - D -  Implantable Cardioverter Defibrillator  40cc; 89g $52,000.00

 Model M177, M179 with cardiac resynchronisation Therapy

 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

Group 4 - Cardiothoracic Atrio-Ventricular Rings and Bands

 Group 4a - Ring, Standard

 Edwards Lifesciences Pty Ltd

EL028 Baxter Sterile Grafts, Implants &  Carpentier-Edwards Classic Annuloplasty  24mm-40mm $2,200.00

 Prostheses, Non-Animal Origin  Ring. Composition: Titanium Alloy;

 Annuloplasty: Ring-Mitral Ring with  Silicone Rubber; Polyester Fabric

 Holder; Mitral Cosgrove-Edwards  Carpentier-Edwards Physio Annuloplasty

 Annuloplasty System Model 4600;  Ring. Composition: Elgiloy Bands;

 Classic Annuloplasty Ring-Tricuspid Polyester Film Strips; Silicone Rubber;

 Polyester Cloth, Cosgrove-Edwards

 Annuloplasty Band. Composition: Silicone

  Rubber; Polyester Cloth. Carpentier-

 Edwards Tricuspid Ring. Composition:

 Titanium Alloy; Silicone Rubber;

 Medtronic Australasia Pty Ltd

MC005 Medtronic Duran Annuloplasty Ring;  Annuloplasty Devices - Models 610R &  Model 610R 25-35mm & Model  $2,200.00

 Duran Ancore Ring 620R; Duran  620R Silicone / Barium Sulphate, Dacron. 620R 23-35mm

 Ancore Chordal Model 620RG

 Sorin Group

SA127 AnnuloFlo Annuloplasty System Annuloflex Ring or AnnuloFlo Ring 26-36mm $2,200.00

 St. Jude Medical Australia Pty Ltd

SJ035 SJM Tailor Annuloplasty Ring Fully Flexible 25mm - 35mm $2,200.00

Prostheses List by Category, Groups and Sponsor Page 19 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Group 4b - Ring, with modification

 Edwards Lifesciences Pty Ltd

EL049 Edwards Etlogix Annuloplasty Ring Titanium/silicon/dacron polyester  24mm/26mm/28mm/30mm/32m $2,400.00

 cloth/plastic template Mitral valve annular  m/34mmd

 repair device designed specifically for

 patients with Ischemic Mitral regurgitation

EL057 Geoform Geoform annuloplasty ring Model 4200  26, 28, 30 and 32mm $2,400.00

 with Holder

 Medtronic Australasia Pty Ltd

MC745 CG Future Composite Ring Semi-rigid mitral annuloplasty ring, with  24, 26, 28, 30, 32, 34, 36 &  $2,400.00

 anterior flexibility

MC844 Profile 3D Annuloplasty Ring 3D, rigid annuloplasty ring with  Diameter (mm) 24 - 40mm $2,400.00

 physiologic mitral valve shape

 St. Jude Medical Australia Pty Ltd

SJ087 St Jude Medical Rigid Saddle Ring Rigid Annuloplasty Ring 24 - 34mm $2,400.00

 Group 4c - Band, Standard

 Edwards Lifesciences Pty Ltd

EL050 Edwards MC3 Tricuspid Annuloplasty  Annuloplasty Ring,  26mm to 36mm in 2mm  $2,400.00

 System titanium/silicone/polyester velour

 cloth/plastic template

 Group 4d - Band, with modification

 Medtronic Australasia Pty Ltd

MC709 Posterior Annuloplasty Band;  Colvin -  Annuloplasty - Model 610B & 620B  Model 610B: 25-35mm; Models  $2,200.00

 Galloway Future Band Model 638B;  Silicone / Barium Sulphate, Dacron.  620B & 620BG: 23-35mm,

 Duran Ancore Band 620B; Duran  Models 638B semi-regid metal alloy core,  Model 638B - 26-38mm

 Ancore Chordal Model 620BG silicone coating, polyester knit fabric, kit

 includes-band, malleable handle, template

 with suture markers, sizers

 St. Jude Medical Australia Pty Ltd

SJ088 SJM Tailor Annuloplasty Band Flexible double-velour, polyester fabric 25 - 35mm $2,200.00

Prostheses List by Category, Groups and Sponsor Page 20 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

Group 4: Single Chamber Pacemakers

 Generation 1

 St. Jude Medical Australia Pty Ltd

SJ053 Verity Adx Model XL SC 5056  Single Chamber multi-programmable rate- 10.5cc, 23g $4,264.00

 implantable pacemaker adaptive pacing device with extended

 longevity

 Generation 2

 St. Jude Medical Australia Pty Ltd

SJ076 Verity Adx Model  XL SR 5157 M/S  Single Chamber  multi-programmable  11cc, 23g $5,928.00

 implantable pacemaker rate-adaptive pacing devices with

 extended longevity

 Generation 3

 Biotronik Australia Pty Ltd

BT046 Protos VR/CLS Single chamber rate responsive, closed  One size only $5,928.00

 loop system.

BT062 Philos II SR Multiprogrammable, Rate Responsive,  One size only $5,928.00

 SSIR pacemaker

BT080 Cylos VR single chamber dual sensor rate responsive one size only $5,700.00

BT106 Cylos 990 SR Single-chamber pacemaker with Closed  57 x 39 x 6mm / 27g $5,928.00

 Loop Stimulation (CLS)

 Boston Scientific Australia Pty Ltd

BS124 Insignia AVT 1192 Single chamber pacemaker 10cc, 23.4g $6,000.00

BS145 Altrua 20 SR Single chamber pacemaker 10cc - 15cc $5,928.00

BS147 Altrua 40 SR Single Chamber pacemaker 10cc - 15cc $5,928.00

BS149 Altrua 50 SR Single chamber pacemaker 10cc - 15cc $5,928.00

BS152 Altrua 60 SR Single Chamber 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

Prostheses List by Category, Groups and Sponsor Page 21 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

GU126 Insignia Plus SR Model 1194 Single Chamber Rate Responsive  One size only $5,928.00

 Permanent Pacemaker

GU139 Insignia Ultra SR Lodel 1190 Implantable Cardiac Pacemaker One size only $5,928.00

 Medtronic Australasia Pty Ltd

MC728 Adapta Pacemaker SR PacemakerModels ADSR01,  9.7 - 11.0cc21.5 - 22.5g $5,928.00$6,188.00

 ADSR06, ADSR03

 Sorin Group

SA137 Symphony SR Titanium one size only $5,928.00

SA142 Reply™ SR Single chamber permenent pacemaker  37 x 41.5 x 6.1mm $5,928.00

 with rate response modulation 19 Grams

 7.5 cm3

 St. Jude Medical Australia Pty Ltd

SJ055 Integrity ADx Model SR 5160  Single Chamber multi-programmable rate- 8cc, 17g $5,928.00

 implantable pacemaker adaptive pacing device

SJ060 Identity ADx Model SR 5180  Single Chamber multi-programmable rate- 8cc, 18g $5,928.00

 implantable pacemaker adaptive pacing device

SJ077 Verity Adx Models XL SR 5156  Single Chamber  multi-programmable  11cc, 23g $5,928.00

 implantable pacemaker rate-adaptive pacing devices with

 extended longevity

SJ090 Victory SR 5610 single chamber rate responsive  41x44x46mm 17g 8cc $5,928.00

SJ105 Zephyr SR 5620 Single Chamber Rate-Responsive  8cc, 17g $5,928.00

SJ131 Zephyr XL SR 5626 Single-Chamber Rate-Responsive  23.5g and 10.4cc $5,928.00

 a

 St. Jude Medical Australia Pty Ltd

SJ027 St Jude Medical Microny II SR+ Model  Single Chamber Rate Responsive  Volume 5.9cc, Weight 12.8gm $5,928.00

 2525T Pacemaker

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

Prostheses List by Category, Groups and Sponsor Page 22 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

AB068 Supple Peri-Guard (6 x 8cm) Model No PC0608SN -6 x 8cm Bovine  6 x 8cm $610.00

 pericardium patch

AB069 Supple Peri-Guard (4 x 4cm) Model No PC0404SN - 4 x 4cm Bovine  4 x 4cm $350.00

 pericardium patch

 Edwards Lifesciences Pty Ltd

EL033 Baxter Augmentation / Substitution  Edwards Pericardial Patch. Bovine  10cm x 16cm $760.00

 Material, Human or Animal Origin,  Pericardium.

 Sterile Pericardial Patch.

 Group 5b - Synthetic, Cardiovascular

 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

Prostheses List by Category, Groups and Sponsor Page 23 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

Group 5: Dual Chamber Pacemakers

 Generation 1

 Boston Scientific Australia Pty Ltd

BS123 Insignia AVT 882 VDD Pacemaker 10.0cc, 23.5g $5,200.00

BS150 Altrua 50 VDD VDD Pacemaker 10cc - 15cc $5,200.00

 Guidant Australia Pty Ltd

GU079 Pulsar Model VDD 870 Titanium 3.2mm/IS-1 $5,200.00

 St. Jude Medical Australia Pty Ltd

SJ050 Verity ADx Model XL DC 5256 Dual -  Dual Chamber multi-programmable rate- 11cc, 23.5g $5,200.00

 Chamber pacemaker adaptive pacing devices with extended

 longevity

SJ061 Identity Adx Model XL DC 5286 Dual  Identity ADx Model XL DC Model 5286  11cc, 23.5g $5,200.00

 Chamber Pacemaker is an implantable, multi-programmable

 rate-adaptive pacing device with AF

 Generation 2

 Medtronic Australasia Pty Ltd

MC713 Adapta Pacemaker VDDR PacemakerModels ADVDD01 11.1cc23.6g $6,760.00

 St. Jude Medical Australia Pty Ltd

SJ054 Identity ADx Model VDR 5480  Single Chamber multi-programmable rate- 8cc, 18g $6,760.00

 implantable pacemaker adaptive pacing device with extended

 longevity

SJ057 Verity ADx Model XL VDR 5456  Single Chamber multi-programmable rate- 11cc, 23.5g $6,760.00

 implantable pacemaker adaptive pacing device with extended

 longevity

 Generation 3

 Biotronik Australia Pty Ltd

BT029 Philos DR-A Model 122600 Implantable  Multiprogrammable, rate responsive,  5mm ports, One size only $9,360.00

 Pacemaker

BT047 Protos DR/CLS Dual chamber, rate responsive, closed  One size only. $9,360.00

 loop system.

Prostheses List by Category, Groups and Sponsor Page 24 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

BT060 Philos II DR Multiprogrammable, rate responsive,  One size only $9,360.00

BT071 Philos II DR-T Dual Chamber Rate Responsive with  One size only $9,360.00

 Home Monitoring

BT079 Cylos DR-T Dual chamber dual sensor rate responsive one size $9,360.00

  with home monitoring system option

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 $12,440.00

 Loop Stimulation (CLS) and Biotronik

 Home Monitoring Technology

 Boston Scientific Australia Pty Ltd

BS126 Insignia AVT 1292 Dual chamber pacemaker 10.8cc, 25.4g $9,360.00

BS144 Altrua 20 DR Dual chamber pacemaker with rate  10cc - 15cc $9,360.00

BS146 Altrua 40 DR Dual Chamber pacemaker 10cc - 15cc $9,360.00

BS148 Altrua 50 DR Dual chamber pacemaker 10cc - 15cc $9,360.00

BS151 Altrua 60 DR Dual Chamber pacemaker 10cc - 15cc $9,360.00

 Guidant Australia Pty Ltd

GU120 Insignia Plus DR Model 1297, Insignia  Dual Chamber Rate Responsive  One size only $9,360.00

 Plus DR Model 1298 Permanent Pacemaker

GU121 Insignia Entra DR Models  Dual Chamber Rate Responsive  One size only $9,360.00

 Permanent Pacemaker

GU140 Insignia Ultra DR Model 1291 Implantable Cardiac Pacemaker One size only $9,360.00

GU141 Insignia Ultra DR Model 1290 Implantable Cardiac Pacemaker One size only $9,360.00

 Sorin Group

SA136 Symphony DR 2550 Active Implantable pacemaker 1 size only $9,360.00

SA141 REPLY TM DR Dual Chamber permanent Pacemaker  8cc, Weight: 20grams,  $9,360.00

 with Rate Response Modulation Dimensions:41.2 x 41.5 x

 St. Jude Medical Australia Pty Ltd

SJ051 Verity Adx Implantable Pacemaker,  Dual - Chamber, multi-programmable,  45x52x6mm,11cc, 23g, 5mm or $9,360.00

 Models XL DR 5356 and XL DR  rate-responsive pacemaker withAF   6mm M/S

SJ056 Integrity ADx Model DR 5360 and XL  Dual-Chamber, multi-programmable, rate- Model DR 5360 - 8cc, 18g,  $9,360.00

 DR 5366 responsive pacemaker with AF  Model XL DR 5366 - 11cc, 23.5g

Prostheses List by Category, Groups and Sponsor Page 25 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

SJ059 Identity ADx Models DR 5380 and XL  Dual-Chamber, multi-programmable, rate- ADx DR 5380: 43x44x6mm,  $9,360.00

 DR 5386 adaptive pacing devices with AF  18g and 8ccADx XL DR

 5386: 44x52x6mm, 23.5g and

SJ089 Victory XL DR 5816 and DR 5810 Dual Chamber Rate Responsive  44x52x6mm; 23.5g; 11cc $9,360.00

 b

 Medtronic Australasia Pty Ltd

MC360 EnRhythm Model P150 1DR, Rate Responsive dual  21g, 13cc $11,440.00

 chamber pacemaker with Anti-

 Tachycardia functions: DDDRP

 Generation 4

 Medtronic Australasia Pty Ltd

MC726 Adapta Pacemaker DR PacemakerModels ADDR01,  11.1-14.2cc23.6g-31.3g $11,440.00

 ADDRS1, ADDRL1, ADDR06, ADDR03

 St. Jude Medical Australia Pty Ltd

SJ103 Zephyr XL DR 5826 and DR 5820 Dual Chamber Rate-Responsive  5826 - 23.5g, 11cc and 5820 -  $11,440.00

 18g, 8.5cc

Group 6 - Cardiothoracic Assisted Anastomic Devices

 Medtronic Australasia Pty Ltd

MC680 Spyder Proximal Anastomotic Device 6-clip assembly $590.00

Group 6: CRT Pacemakers

 Generation 1

 Guidant Australia Pty Ltd

GU143 Contak Renewal TR CRT -P Model  Implantable cardiac pacemaker 45x54x8.5mm, 14cc, 26gm $9,360.00

 H120, Model H125

 Generation 2

 Biotronik Australia Pty Ltd

BT085 Stratos LV-T Multiprogrammable Biventricular DDDRV One size only $12,480.00

  with Home Monitoring

Prostheses List by Category, Groups and Sponsor Page 26 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Guidant Australia Pty Ltd

GU142 Contak Renewal TR2 CRT - P Model  Implantable Cardiac pacemaker 45x54x8.5mm, 14cc, 26gm $12,480.00

 H140, Model H145

 Medtronic Australasia Pty Ltd

MC226 Medtronic Insync III Triple Chamber  Titanium One size only $12,480.00

 Pacemaker Model 8042

 St. Jude Medical Australia Pty Ltd

SJ072 Frontier II - Model 5596 Biventricular Cardiac Resynchronisation  49mm(h) x 52(1) x 6(t), 25g $12,480.00

 Device with AF suppression algorithm -

 Titanum

 a

 St. Jude Medical Australia Pty Ltd

SJ150 Promote Accel RF CD3215-36 Cardiac Resynchronisation Therapy  82g, 43cc $47,840.00

 Defibrillator with RF Telemetry

Group 7 - Cardiothoracic Assisted Fixation Devices

 Medtronic Australasia Pty Ltd

MC714 U-Clips (Valve Repair) Double Arm, Mitral Valve Repair 2-packs $510.00

 7b - Other

 Medtronic Australasia Pty Ltd

MC765 U-Clips Nitinol Clips, 8-pack Needle Lengths: 6.5mm -  $336.00

 9.5mm, 8-pack

MC772 U-Clips Nitinol Clips, 2-pack Needle Lengths: 6.5mm -  $84.00

 9.5mm, 2-Pack

Group 7: ICD Leads

 Sub -Group 1: Coronary Sinus Leads

 Medtronic Australasia Pty Ltd

MC026 Medtronic Transvene SVC Lead Model  Model 6937-35, Model 6937-52, Model  35 - 110cm x  660mm $2,340.00

 6937; 6937-58, Model 6937-110; Silicone;

Prostheses List by Category, Groups and Sponsor Page 27 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Sub -Group 2: Subcutaneous Leads

 Guidant Australia Pty Ltd

GU123 Endotak SQ Array XP Lead Model 0085 Endotak SQ Array XP Lead Model 0085  70 cm $4,680.00

 is used in addition to an Endotak

 endocardial leads for patients with a high

 DFT (Defibrillation Threshold)

 Medtronic Australasia Pty Ltd

MC251 Implantable Subcutaneous Defibrillator  Silicone and Platinum Alloy Lengths 41-85cm inclusive $4,680.00

 Lead Model 6996SQ 41cm, 58cm,

 Sub -Group 5: Transvenous/ Steroid/ Passive  Leads

 Biotronik Australia Pty Ltd

BT077 Kentrox SL steriod Dual shock coil fractal steroid eluting  65, 75cm lengths $9,000.00

 passive fixation electrode

BT078 Kentrox RV Steroid single shock coil fractal steroid eluting  65, 75 cm lenghts $9,000.00

 passive fixation electrode

BT092 Linox TD Fractal and steroid coated passive fixation 65, 74 or 100cm length and 16  $9,360.00

  quadripolar ICD lead or 18mm electrode spacing

BT093 Linox T Passive fix RV bipolar fractal coated  65, 75cm length $9,360.00

 steroid ICD lead

 Guidant Australia Pty Ltd

GU112 Endotak Reliance S Lead Model 0127 & Model 0128, defibrillation  59cm, 64cm $7,500.00

 lead, 9fr introducer (silicone coated),

 steroid eluting, high impedence

GU115 Endotak Reliance Lead Model 0147, Model 0148 & Model 0149,  59cm, 64cm, 90cm $7,500.00

 defibrillation lead, 9fr introducer (silicone

 coated), steroid eluting, high impedence

GU158 Endotak Reliance SG Passive Fixation  Endotak Reliance SG Passive Fixation  54cm - 90cm $7,200.00

 Lead: Models 0170, 0171, 0172, and

 0173 Implantable cardioverter defibrillator

  lead with GORE ™ ePTFE covered

GU159 Endotak Reliance G Passive Fixation Lead Endotak Reliance G Passive Fixation  54cm -90cm $7,200.00

 Lead: Models 0174, 0175, 0176 and

 0177. Implantable Cardioverter

 defibrillator lead with GORE ™ ePTFE

Prostheses List by Category, Groups and Sponsor Page 28 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Medtronic Australasia Pty Ltd

MC002 Medtronic Sprint Quattro Lead Model  Silicone and polyurethane 65-100cm $9,360.00

 6944RV/SVC 65cm; Model

 6944RV/SVC 75cm; or Model

 6944RV/SVC 100cm; Medtronic Sprint

 Quattro Lead Model 6944RV/SVC 58cm

 St. Jude Medical Australia Pty Ltd

SJ016 Riata Transvenous Tachyarrhythmia  Quadripolar, dual-coil, steroid eluting,  One size only $9,360.00

 Lead Model 1570, Model 1571 active fixation tachyarrhythmia leads

SJ083 Riata Transvenous Tachyarrhythmia  Tri-polar Passive-Fixation, Steroid  60cm, 65cm, 8F introducer $9,360.00

 Lead Model 1572 Eluting, Single Shock Coil

SJ085 Riata iTransvenous Tachyarrhythmia  Passive Fixation, Steroid-Eluting, Dual  60cm, 65cm, 70cm, 8F  $9,360.00

 Leads Models 1560 and 1561 Shock Coil Defibrillation Lead

SJ086 Riata i Transvenous Tachyarrhythmia  Passive Fixation, Steroid Eluting, Single  60cm, 65cm, 70cm, 8F  $9,360.00

 Lead Model 1562 Shock Coil Defibrillation Lead

SJ110 Riata ST Transvenous Tachyarrhythmia Riata ST 7040/41 Passive-Fixation True- 60 - 75cm, 6.3 Fr, 7 Fr  $9,360.00

  Leads 7040/41/42 and 7050/51/52 Bipolar, Dual-Coil, Steroid-eluting,

 Endocardial Defibrillation Leads, 7042 -

 Single Coil, 7050/51 - Integrated Bipolar,

 Dual Coil, 7052 - Integrated Bipolar,

 Single Coil

SJ113 Riata i TransvenousTachyarrhythmia  Riata i 1950/51 - Passive-Fixation  60 - 75cm $9,360.00

 Leads  1950/51 Integrated-Bipolar, Dual-Coil, Steroid-

 Eluting, Endocardial Defibrillation Leads

SJ130 Riata ST Optim 7070/1 Passive Fixation, True bipolar, Dual Coil,  60, 65 and 70cm length, 7Fr  $9,360.00

 Steroid Eluting, Endocardial Defibrillation  introducer

 Leads with Optim insulation overlay

SJ158 Durata 7170, 7171 Passive fixation, true bipolar, dual coil,  60, 65 and 70cm $9,360.00

 steroid eluting, endocardial defibrillation

 leads with Optium insulation overlay

 Sub -Group 6: Transvenous/ Steroid/ Active Leads

 Biotronik Australia Pty Ltd

BT064 Kentrox SL-S steroid Fractal coated steroid electrode, dual  16 and 18 cms tip to second  $7,488.00

 shock coil shock coil

BT068 Kentrox RV-S steroid Fractal coated steroid electrode, single  65cm lengths $7,488.00

 shock coil

Prostheses List by Category, Groups and Sponsor Page 29 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

BT084 Linox SD Fractal coated and steroid electrode,  65, 75cm length, 16, 18mm elec $9,360.00

 active fixation quadrapolar

BT096 Linox S Active fix RV bipolar fractal coated  65, 75cm length $9,360.00

 steroid IC lead

 Guidant Australia Pty Ltd

GU118 Endotak Endurance EZ Leads Model  Defibrillation lead, steroid eluting,  64, 70, 100cm $7,500.00

 0154, Model 0155, Model 0156 trilumen lead body contains one

 conductor for pacing/sensing and two

 conductors for defibrillation.  The helix is

  composed of platinum iridium.

GU145 Endotak Reliance G Lead Model 0164,  Implantable defibrillator/pacemaker lead Lead Lengths: 59 - 90cm $9,000.00

 Model 0165, Model 0166, Model 0167

GU146 Endotak Reliance SG Lead Model 0160,  Implantable defibrillator/pacemaker lead Lead Lengths: 59 - 90cm $9,000.00

 Model 0161, Model 0162, Model 0163

GU160 Endotak Reliance Active Fixation Lead Endotak Reliance Active Fixation Lead:  54cm - 90cm $7,200.00

 Models 0157, 0158 and 0159 Implantable

 cardioverter defibrillator lead

GU161 Endotak Reliance S Active Fixation Lead Endotak Reliance S Active Fixation Lead:  54cm - 90cm $7,200.00

 Models 0137, 0138 and 0139

GU163 ENDOTAK RELIANCE G Lead 018  Endotak Reliance G Lead: Models 0184 to 59-90cm $7,200.00

  0187.  Implantable cardioverter

 defribrillator lead.  Active fixation.

GU164 ENDOTAK RELIANCE SG Lead 018  Endotak Reliance SG Lead: Models 0180  59-90cm $7,200.00

 Series to 0183.  Implantable cardioverter

 defibrillator lead.  Active fixation.

 Medtronic Australasia Pty Ltd

MC208 Medtronic Sprint Quattro Secure Lead  Leads, Defibrillator, Implantable, Silicone, 58-100cm $9,360.00

 Model 6947 58cm; Model 6947 65cm;   polyurethane, platinized tantalum coils,

 Model 6947 75cm; Model 6947 100cm steroid eluting tip

MC834 Sprint Quattro Secure S Model 6935, Active Fixation Single Coil  52 - 100cm $9,360.00

 Defibrillation Lead

 St. Jude Medical Australia Pty Ltd

SJ074 Riata Transvenous tachyarrhythmia  Tri-polar Active - Fixation, Steroid- 60cm, 65cm, 8F introducer $9,360.00

 Leads Model 1582 Eluting, Single shock Coil

SJ075 Riata Transvenous Tachyarrhythmia  Quadripolar, dual-coil, steroid eluting,  One size only $9,360.00

 Lead Model 1580, Model 1581 active fixation tachyarrhythmia leads

Prostheses List by Category, Groups and Sponsor Page 30 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

SJ081 Riata i Transvenous Tachyarrhythmia  Active fixation leads, Steroid Eluting,  60cm, 65cm, 75cm, 8F  $9,360.00

 Leads Model 1590/1591 Dual Shock Coil Defibrillation Lead

SJ084 Riata i Transvenous Tachyarrhythmia  Active Fixation, Steroid Eluting, Single  60cm, 65cm, 75cm, 8F  $9,360.00

 Lead Model 1592 Shock Coil Defibrillation Lead

SJ096 Riata ST 7000/7001/7002 Active-Fixation True-Bipolar, Dual-Coil,  60, 65cm 7F introducer $9,360.00

 (7002 - Single-Coil) Steroid-Eluting

 Steroid Eluting, Endocardial Defibrillation

SJ102 Riata ST Transvenous Tachyarrhythmia Riata ST 7010/7011 Active-Fixation  60 - 75cm 6.3Fr, 7 Fr Introducer $9,360.00

  Leads 7010/7011/7012 Integrated-Biopolar, Dual-Coil, Steroid-

 eluting, Endocardial Defibrillation Leads,

 7012 - Single Coil

SJ106 Riata Transvenous Tachyarrhythmia  Riata 1940/41 Active-Fixation True- 60-75cm $9,360.00

 Leads 1940/41/42 bipolar, Dual-Coil, Steroid-eluting,

 Endocardial Defibrillation Leads, 1942 -

SJ108 Riata i Transvenous Tachyarrhythmia  Riata i 1962 - Active Fixation Integrated- 60 - 75cm $9,360.00

 Leads 1962 Bipolar, Single-Coil, Steroid-Eluting,

 Endocardial Defibrillation Leads

SJ122 Riata ST Optim 7020/1/2 and 7030/1 7020/1 - Active fixation, true bipolar,  60, 65 and 75cm length and 7Fr  $9,360.00

 7022 - Active fixation, true bipolar -  introducer

 single coil, 7030/1 - Active fixation,

 integrated bipolar, dual coil steroid eluting

  endocardial defibrillation leads with

 Optim insulation overlay

SJ157 Durata 7120, 7121, 7122, 7130, 7131 Active fixation bipolar, dual-coil/single  60, 65, 75cm $9,360.00

 coil Steroid-eluting Endocardial

 Defibrillation Leads

 Sub -Group 7: Epicardial Patches

 Medtronic Australasia Pty Ltd

MC027 Model 6721 Unipolar Epicardial Patch  Model 6721S-50, Model 6721M-50,  370, 660, 840mm $2,340.00

 Leads S/M/L Model 6721L-50; Silicone

Prostheses List by Category, Groups and Sponsor Page 31 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

Group 8 - Cardiothoracic Grafts (Proximal Aorta)

 Group 8b Modified Tube

 Terumo Corporation Australia

TU036 Gelweave Valsalva Graft Woven vascular prosthesis, polyester,  Diameter 24 - 34 mm, Overall  $3,320.00

 gelatin sealed length 18.4 - 19.6cm

 Group 8c Tube with one side branch

 Terumo Corporation Australia

TU038 Gelweave Graft Straight Thoracic Graft, with antiflo side  20 -34 mm x 20-40 cm $1,715.00

 branch, Polyester, woven, gelatin sealed

 Group 8d Tube with multiple side branches (more than 1)

 Terumo Corporation Australia

TU037 Gelweave Plexus Graft Multi Branched, for Aortic Arch  20 - 34 mm x 40 cm $2,150.00

 reconstruction, Polyester, Woven, gelatin

 sealed

Group 8: Pacemaker Leads

 Sub-Group 1: Non-transvenous, Bi-Polar, Steroid

 Medtronic Australasia Pty Ltd

MC011 Capsure EPI steroid eluting bipolar  Silicone 25 - 60cm $1,716.00

 epicardial lead Model 4968 - ventricle

 St. Jude Medical Australia Pty Ltd

SJ132 Myodex 1084T Steroid-Eluting Bipolar Sutureless  35cm and 54cm $1,716.00

 Myocardial Pacing Lead with Titanium

 Nitride Electrodes

SJ140 Myodex 1084T and FasTac Flex Lead  Steroid -Eluting Bipolar Sutureless  35cm and 54cm, Lead implant  $1,966.00

 Implant Tool Myocardial Pacing Lead with Titanium  tool - 44cm

 Nitride Electrodes and Lead implant tool

 with articulating distal end.

Prostheses List by Category, Groups and Sponsor Page 32 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Sub-Group 11: Transvenous, Bi-Polar, Passive, Steroid, Left Ventricular

 Biotronik Australia Pty Ltd

BT095 Corox OTW BP Coronary Sinus bipolar steroid 77, 87 cm length $6,240.00

 Guidant Australia Pty Ltd

GU138 Easytrak 2, Model 4514,4515, 4516,  The Easytrak 2 lead is a dual electrode  . $6,240.00

 4517, 4518, 4519, 4520 version of the Easytrak lead.  The

 Easytrak 2 lead is a coronary sinus lead,

 steroid eluting, dual electrode, pace/sense

 lead.  The lead provides chronic pacing

 and sensing of the left ventricle by

GU153 Easytrak 2 Is-1 Lead - Models 4542,  Implantable left ventricular pacemaker lead 80 to 100cm $6,240.00

 4543 & 4544

GU156 Easytrak 3 Lead - Models 4521, 4522,  Implantable left ventricular pacemaker lead 80 to 100cm $6,240.00

 4523, 4524, 4525, 4526 and 4527

GU162 Easytrak 3 IS-1 Lead Models 4548, 4549 and 4550. Silicone  Sizes 80 to 100cm $6,240.00

 and polyurethane insulation and

 polyurethane protective sleeve

GU165 Acuity Steerable Lead Steerable IS-1 bipolar CS LV Lead 80cm, 90 cm, 100cm $6,240.00

 Models 4554, 4555, 4556

 Medtronic Australasia Pty Ltd

MC699 Attain OTW Model 4194 Lead Model 4194 78cm, 88cm $6,240.00

MC811 Attain Ability 4196 LV Lead Over the wire dual electrode left  78, 88, and 103 cm $6,240.00

 ventricular lead

 St. Jude Medical Australia Pty Ltd

SJ099 QuickSite 1056T Bipolar Steroid-Eluting, Titanium Nitride  75cm, 6F and 86cm, 6F $6,240.00

 Coated Electrodes Guidewire/Stylet-

 Placed Keft Heart Lead with Fast-Pass

SJ139 Quickflex 1156T and XL 1158T Bipolar, Steroid-Eluting, Titanium Nitride  Length 75 and 86cm $6,240.00

 Coated Elextrodes, Guidewire/Stylet-

 Placed Left Heart Lead with Fast-PassTM

Prostheses List by Category, Groups and Sponsor Page 33 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Sub-Group 13: Transvenous, Active, Steroid, Left Ventricular

 St. Jude Medical Australia Pty Ltd

SJ126 QuickSite XL 1058T Bipolar, Steroid-Eluting, Titanium Nitride  75-86cm $6,240.00

 Coated Electrodes, Guidewire/Stylet-

 Placed Left Heart Lead with Fast-Pass

 Sub-Group 2: Non-transvenous, Uni-Polar, Steroid

 Medtronic Australasia Pty Ltd

MC053 Capsure EPI steroid eluting unipolar  Silicone 25 - 50cm $1,544.00

 epicardial lead Model 4965 ventricle

 Sub-Group 3: Non-transvenous, Uni-Polar, Non-Steroid

 Guidant Australia Pty Ltd

GU037 Myocardial Pacing Lead Model 4312 and 4316 54cm and 35cm $1,144.00

 Medtronic Australasia Pty Ltd

MC009 Medtronic Epicardial Pacing Leads IS-1  Silicone 35 - 53cm $1,144.00

 Model 5071

 Sub-Group 4: Transvenous, Uni-Polar, Passive, Steroid, Right Ventricular/Atrial

 Medtronic Australasia Pty Ltd

MC254 CapSure Sense pacemaker lead Models  Titanium Nitride 30 - 85cm $1,248.00

 St. Jude Medical Australia Pty Ltd

SJ078 IsoFlex S, Models 1645K, 1643K,  Endocardial, Steroid Eluting, Silicone,  34cm, 40cm, 46cm, 52cm,  $1,248.00

 Passive Fixation Leads with Fast-Pass  58cm, 85cm, 7F

 Sub-Group 5: Transvenous, Uni-Polar, Passive, Non-Steroid, Left Ventricular

 St. Jude Medical Australia Pty Ltd

SJ033 Aescula LV Model 1055K Left Ventricular Pacing Lead 75cm $2,735.00

Prostheses List by Category, Groups and Sponsor Page 34 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Sub-Group 6: Transvenous, Uni-Polar, Passive, Steroid, Left Ventricular

 Biotronik Australia Pty Ltd

BT070 Corox OTW UP Steroid Coronary Sinus Lead 77, 87cm $3,000.00

 Boston Scientific Australia Pty Ltd

BS133 Acuity Spiral Transvenous Left Ventricular pacing lead 80, 90 & 100cm $5,000.00

 Guidant Australia Pty Ltd

GU056 Easytrak Lead Model 4510, Model 4511, Model 4512  65cm, 72cm, 80cm $3,120.00

 Transvenous Coronary Sinus Lead

GU152 Easytrak IS-1 Lead, Models 4535 to 4538 Implantable left ventricular pacemaker lead 80 - 90cm $3,120.00

 Medtronic Australasia Pty Ltd

MC225 Attain Over the Wire Model 4193 Titanium, polyurethane 78-88cm $3,120.00

MC730 Attain StarFix LV Lead Over the wire left Ventrucular Lead 78, 88, 103cm $5,000.00 $6,240.00

 St. Jude Medical Australia Pty Ltd

SJ079 QuickSite Model 1056K Unipolar, Steroid Eluting, Titanium Nitride 75cm, 6F and 86cm, 6F $3,120.00

  Electrode, Guidewire/Stylet-placed Left

 Heart Lead with Fast-Pass Coating

 Sub-Group 8: Transvenous, Bi-Polar, Passive, Steroid, Right Ventricular/Atrial

 Biotronik Australia Pty Ltd

BT066 Selox ST Transvenous Bipolar Passive Steroid  53 and 60cm lengths $1,248.00

 Ventricular Pacing Lead, fractal coated

BT067 Selox JT Fractal coated steroid electrode 45 and 53cm lengths $1,248.00

 Guidant Australia Pty Ltd

GU009 Fineline II Sterox IROX Lead Model 4458, Model 4459 52cm, 58cm $1,248.00

GU011 Fineline II Sterox IROX Lead Model 4456, Model 4457 52cm, 58cm $1,248.00

GU012 Fineline II Sterox IROX Lead Model 4479, Model 4480 45cm, 52cm $1,248.00

GU023 Guidant Aust Selute Picotip Steroid  Model 4033, Model 4034, Model 4035,  45cm , 52cm, 59cm $1,248.00

 Eluting Bipolar Lead Model 4063, Model 4064

Prostheses List by Category, Groups and Sponsor Page 35 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Medtronic Australasia Pty Ltd

MC010 Medtronic Capsure SP Novus Model  Silicone Polyurethane 45 -110cm $1,144.00

 5092; Capsure SP Novus Lead Model

 5592; Medtronic Capsure Model 4023

 Lead; Medtronic Capsure Model 4024

 Lead (med.dexamethasone) Medtronic

 Capsure Model 4523(MED) Medtronic

 Capsure Model 4524 Lead; Medtronic

 Capsure Model

MC229 Medtronic Capsure SP Novus Model  Silicone, platinum 30-100cm $1,144.00

 5594 Lead 30cm

MC336 Medtronic Capsure Z Novus Model  Silicone; Contents: 1 x lead with  45-58cm $1,248.00

 5054 Pacing Lead anchoring sleeve, stylet & guide, 1 x vein

 lifter, 2 x fixation tools, extra stylets

MC337 Medtronic Capsure Z Novus Model  Silicone; Contents: 1 x lead with  45-58cm $1,248.00

 5554 Pacing Lead anchoring sleeve, stylet & guide, 1 x vein

 lifter, 2 x fixation tools, extra stylets

MC371 Medtronic Capsurefix Model 6940  Silicone Polyurethane 30 - 85cm $1,144.00

 Pacing Lead;  Medtronic Tined IS-1

 Model 4557M; Medtronic Capsurefix

 Model 4067/8/4568 Pacing Leads; 

 Medtronic Capsurefix Model 5067

 Pacing Leads; Medtronic Capsurefix

 Model 5068 Pacing Leads; Capsure SP

MC372 CapSure Sense pacemaker lead Models  Titanium Nitride CapSure Sense Lead Model  $1,248.00

 4074 & 4574 4074 - 30cm to 85cm; CapSure

 Sense Lead Model 4574 - 30cm

 St. Jude Medical Australia Pty Ltd

SJ024 PASSIVE PLUS DX 1342T, 1343K,  Single, passive fixation, steroid eluting,  46-58cm $1,248.00

 1345K, 1346T low polarisation lead; Models: Bipolar

 Atrial Lead, IS-1 Unipolar Atrial Lead, IS-

 1 Unipolar Ventricular Lead, IS-1 or

 Bipolar Ventricular Lead, IS-1

SJ082 Isoflex S, Models 1646T, 1642T and  endocardial, Steroid Eluting, Silicone,  34cm, 40cm, 46cm, 52cm,  $1,248.00

 Passive Fixation Pacing Leads with Fast- 58cm, 85cm, 7F, 120cm 8F

 Pass Coating

SJ097 Isoflex P 1644T and 1648T Endocardial, Steroid Eluting,  1648T - 34-85cm 1644T - 34- $1,248.00

 Polyurethane, Passive-Fixation Bipolar

 Pacing Leads with Fast-Pass Coating

Prostheses List by Category, Groups and Sponsor Page 36 of 871

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

SJ146 Isoflex 1944T & 1948T Passive-Fixation, Bipolar, Steriod Eluting,  46cm, 52cm, 58cm $1,248.00

 Endocardial Pacing Lead with Optim

 insulation

 b

 Guidant Australia Pty Ltd

GU028 Guidant Aust Selute Picotip VDD Lead Model 4340, Model 4341, Model 4342 &  . $1,544.00

 Model 4343

 Medtronic Australasia Pty Ltd

MC052 Medtronic Capsure VDD2 Model 5038  Silicone; Contents: 1 x lead with  11.5cm, 13.5cm, 15.5cm $1,544.00

 AV Pacing Lead anchoring sleeve, stylet & guide, 1 x vein

 lifter, 2 x fixation tools, extra stylets

 Sub-Group 9: Transvenous, Bi-Polar, Active, Steroid, Right Ventricular/Atrial

 Biotronik Australia Pty Ltd

BT063 Selox SR Lead, pacemaker, implantable,  45, 53, 60cm length $1,248.00