Private Health Insurance (Prostheses) Rules 2010

(No. 2)

As amended

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

This compilation was prepared on 19 January 2011 taking into account amendments up to the Private Health Insurance (Prostheses) Amendment Rules 2010 (No.2).

Prepared by the Department of Health and Ageing, Canberra.

Contents

Part 1 Preliminary 

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 7

10. Listing criteria for prostheses to be listed on Part C of the Schedule 7

Part 1 Preliminary

1.                      Name of Rules

These Rules are the Private Health Insurance (Prostheses) Rules 2010 (No. 2).

2.                      Commencement

These Rules commence on 14 August 2010.

3.                      Revocation

These Rules revoke the Private Health Insurance (Prostheses) Rules 2010 (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.

certified overnight Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.

certified Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.

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

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

implantable cardiac event recorder includes a component of an implantable cardiac event recorder.

insulin infusion pump includes a component of an insulin infusion pump.

listing application has the same meaning as in subsection 72-10(6) of the Act.

listing criteria has the same meaning as in subsection 72-10(6) of the Act.

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

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

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

professional attendance has the same meaning as in clause 1.2.3 of the Health Insurance (General Medical Services Table) Regulations 2010.

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

Schedule means the Schedule in these Rules.
 

Part 2 Benefit requirements

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; or

  (iii)        for a prosthesis that is an insulin infusion pump:

(A)                          the insulin infusion pump is provided during a professional service for which a medicare benefit is payable; and

(B)                          the professional service is a professional attendance by a consultant physician in the practice of his or her specialty; and

(C)                          the professional service is provided as a certified Type C procedure or certified overnight Type C procedure; and

(D)                          the insulin infusion pump is provided for the purpose of administering insulin; and

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

(d)                    rule 10 sets out listing criteria for the purposes of subsection       72-10(6) of the Act in relation to the granting of a listing application for listing of a kind of prosthesis on Part C of the Schedule.

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.

10.                  Listing criteria for prostheses to be listed on Part C of the Schedule

For a listing application to list a kind of prosthesis on Part C of the Schedule, the listing criteria are that the kind of prosthesis is an:

(i) insulin infusion pump; or

(ii) implantable cardiac event recorder.

Note: The Minister may refuse to grant a listing application even if the listing

criteria are satisfied.

Notes

The Private Health Insurance (Prostheses) Rules 2010 (No.2) as shown in this compilation are amended as indicated in the tables below.

Table of Instruments

Table of Amendments

1. All legislative instruments and compilations are registered on the Federal Register of Legislative Instruments kept under the Legislative Instruments Act 2003. See www.frli.gov.au

Schedule

Part A - Prostheses List August 2010

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

Group 1- Cardiothoracic Mechanical Valves

 Group 1c - Bi-Leaflet, rotatable

 Advanced Biomedical Pty Ltd

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

 model 500FA standard flexi-cuff aortic  Polyester, Titanium

 valve series, ATS medical open pivot

 heart valve model 500DM standard

 flexi-cuff mitral valve series

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

 model 501DA advanced performance  Polyester, Titanium

 (AP) aortic valve series, ATS medical

 open pivot heart valve model 501DM

 advanced performance (AP) mitral valve

 Medtronic Australasia Pty Ltd

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

 A7760

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

 leaflets Pyrolite carbon ring

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

 Reid Healthcare

RH001 Aortic On-X Prosthetic Heart Valve  27-29mm, 19mm, 21mm,  $6,000.00

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

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

 23; ONXM-25; ONXM-27/29;

 ONXM31/33; ONXMC25/33

 Sorin Group

SA129 Optiform Mechanical Valve 19mm to 33mm $6,000.00

Prostheses List by Category, Groups and Sponsor Page 1 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 St. Jude Medical Australia Pty Ltd

SJ037 St Jude Medical Aortic Expanded Cuff  Aortic Expanded Cuff, Aortic  Aortic Expanded 19 -31mm,  $6,000.00

 Heart Valve; St Jude Medical Aortic  Hemodynamic Plus Cuff, Mitral  Aortic Hemodynamic 17 -

 Hemodynamic Plus Cuff Heart Valve; St Hemodynamic Cuff, Aortic & Mitral  27mm, Mitral Hemodynamic 17

  Jude Medical Mitral Hemodynamic Plus -27mm, Rotatable 17 - 33mm

  Cuff Heart Valve; St Jude Medical

 Mechanical Heart Valve Masters Series

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

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

 17AGFN-756 - 23AGFN-756

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

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

 25AGFN-756 - 29AGFN-756

 Group 1e - Tilting Disc, rotatable

 Medtronic Australasia Pty Ltd

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

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

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

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

 Easy Fit Mitral Heart Valve Model M7700

Group 1: Single Chamber ICD's

 Generation 3

 Guidant Australia Pty Ltd

GU148 Vitality 2 EL VR - Model T177 Single Chamber ICD 35cc; 90g $40,560.00

GU151 Vitality 2 VR - Model T 175 Single Chamber ICD 30cc; 82g $40,560.00

 Sorin Group

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

 6250, 34J

 a

 Sorin Group

SA149 PARADYM VR 8250 Single Chamber implantable cardioverter  Dimensions: 58.4 x 73.4 x  $42,640.00

 defibrillator with rate response 11mm; Weight: 90 grams;

Prostheses List by Category, Groups and Sponsor Page 2 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 St. Jude Medical Australia Pty Ltd

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

 defibrillator

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

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

 a, d

 St. Jude Medical Australia Pty Ltd

SJ142 Analyst VR CD1217-36 Single Chamber Cardioverter Defibrillator  79g, 41cc $42,640.00 $44,640.00

 with RF Telemetry and ST Segment

 Monitoring

 A,C,D

 Medtronic Australasia Pty Ltd

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

 Defibrillator, Single Chamber

 A,D

 Biotronik Australia Pty Ltd

BT090 Lumax 340 VR-T ICD-VR 34 J with bidirectional Home  One size only $42,640.00 $45,640.00

 Monitoring. Single chamber

BT098 Lumax 340 VR-T XL ICD-VR with 40 J output, bidirectional  One Size Only $42,640.00 $45,640.00

 Home Monitoring and High Longevity

 Boston Scientific Australia Pty Ltd

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

 Medtronic Australasia Pty Ltd

MC939 Virtuoso II VR Model - Implantable Cardioverter  37cc, 68g $42,640.00

 Defibrillator, Single Chamber

 St. Jude Medical Australia Pty Ltd

SJ124 Current RF VR 1207-36 Single Chamber Cardioverter Defibrillator  79g, 41cc $42,640.00

 with RF Telemetry

 A,D,E

 Boston Scientific Australia Pty Ltd

BS132 Teligen 100 HE VR 4-SITE Single chamber ICD, high energy with  30.5cc, 9.9mm $43,390.00

Prostheses List by Category, Groups and Sponsor Page 3 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 D

 Biotronik Australia Pty Ltd

BT087 Lumax 300 VR-T ICD-VR with bidirectional Home  One Size Only $40,560.00 $43,560.00

 Monitoring. Single chamber

 St. Jude Medical Australia Pty Ltd

SJ216 AnalyST VR CD1217-30 Single chamber cardioverter defibrillator  73g, 37cc $40,560.00 $42,560.00

 with RF telemetry and ST segment

 Generation 4

 a, d, e

 St. Jude Medical Australia Pty Ltd

SJ232 Current Accel VR CD1215-36Q Single Chamber Cardioverter Defibrillator  80g, 42cc $44,670.00

 with RF Telemetry and SJ4 connector

SJ237 AnalyST Accel VR CD1219-36Q Single Chamber Cardioverter Defibrillator  79g, 41cc $44,670.00

 with RF Telemetry and ST Segment

 Monitoring and SJ4 connector.

 A,D

 Biotronik Australia Pty Ltd

BT100 LUMAX 540 VR-T High Energy, Single-Chamber ICD  Diamensions: 66*55*13 mm  $43,920.00 $45,640.00

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

 Advanced Patient Management Via unique

  Home Monitoring Technology

 incorporatin Automatic Threshold

 Monitoring and Extended Longevity.

 Medtronic Australasia Pty Ltd

MC813 Secura VR Fully Automatic, Wireless Implantable  37cc $43,920.00

 cardioverter defibrillator with high energy

  capability and therapies for ventricular

 tachyarrhythmia

 St. Jude Medical Australia Pty Ltd

SJ147 Current Accel VR RF CD1215-36 Single Chamber Cardioverter Defibrillator  79g, 38cc $43,920.00 $44,640.00

 with RF Telemetry

SJ154 AnalyST Accel VR CD1219-36 Single Chamber Cardioverter Defibrillator  79g, 41cc $43,920.00 $44,640.00

 with RF Telemetry and ST Segment

 Monitoring

Prostheses List by Category, Groups and Sponsor Page 4 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 D

 St. Jude Medical Australia Pty Ltd

SJ212 AnalyST Accel VR CD1219-30 Single chamber cardioverter defibrillator  73g, 37cc $41,820.00 $44,560.00

 with RF telemetry and ST segment

SJ213 Current Accel VR RF CD1215-30 Single chamber cardioverter defibrillator  73g, 37cc $41,820.00 $44,560.00

 with RF telemetry

Group 10: Pacemaker/ICD Extenders

 Medtronic Australasia Pty Ltd

MC831 Medtronic Lead Extender Kit Model:  Silicone 37 - 50cm $530.00

 6984M, 6981M, 6985M,6986m

Group 11: Pacemaker/Lead Accessories

 Medtronic Australasia Pty Ltd

MC036 Medtronic Lead End Cap Kit Model:  Pin Plug Kits to Seal Unused Pacemaker  One Size Per Model $80.00

 5867-3M; Medtronic DF-1 Port Pin  or Defibrillator Port; Sizing Sleeve -

 Plug Kit: Model 6719, Medtronic IS-1  Silicone or Polyurethane

 Port Pin Plug Kit: Model 6725;

 Medtronic Upsizing Sleeve: Model 5866-

Group 12: Coronary Stents

 Sub-Group 1: General Purpose Drug eluting stents

 Abbott Australasia Pty Ltd

AY023 Xience Everolimus Eluting Stent System Everolimus Eluting Stent System 2.25mm to 4.0mm widths, 8mm $3,450.00

  to 28mm lengths

Prostheses List by Category, Groups and Sponsor Page 5 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

AY037  Xience PRIME LL Everolimus Eluting  Coronary Artery Stent, Drug Eluting XIENCE PRIME LL 2.50; 2.75;  $3,450.00

 Coronary Stent; Xience PRIME  3.00; 3.50; 4.0 x 33MM; 

 Everolimus Eluting Coronary Stent;   XIENCE PRIME LL 2.50; 2.75;

 Xience PRIME SV Everolimus Eluting  3.00; 3.50; 4.0 x 38MM; 

 XIENCE PRIME SV 2.25 x 08;

 12; 15; 18; 23; 28MM; XIENCE

  PRIME 2.50 x 08; 12; 15; 18;

 23; 28MM;  XIENCE PRIME

 2.75 x 08; 12; 15; 18; 23;

 28MM;  XIENCE PRIME 3.00 x

  08; 12; 15; 18; 23; 28MM; 

 XIENCE PRIME 3.50 x 08; 12;

 15; 18; 23; 28MM;  XIENCE

 PRIME 4.00 x 08; 12; 15; 18;

 23; 28MM

 Boston Scientific Australia Pty Ltd

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

 Coronary Stent System Polymer and Paclitaxel

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

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

BS175 PROMUS Element Platinum chromium alloy stent coated  8mm to 38mm with a reference  $3,450.00

 with a blended polymer mixed with  vessel diameter of 2.25mm -

 4.0mm.

BS176 Taxus Element Platinum chromium alloy stent coated  (8mm to 38mm) with a  $3,450.00

 with a blended polymer mixed with  reference vessel diameter of

 Johnson & Johnson Medical Pty Ltd

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

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

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

 28250, 28275, 28300, 33225, 33250,

 33275, 33300, 13225, 13250, 13275,

 18225, 18250, 18275, 18300, 23225,

 23250, 23275, 23350, 23400, 08350,

 08400, 2835

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

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

 anti-proliferative drug) bound to the stent

 by a polymer. Model CRA-23300, 08225,

  08250, 08275, 08300, 28225, 28250,

 28275, 28300, 33225, 33250, 33275,

Prostheses List by Category, Groups and Sponsor Page 6 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

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

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

 Medtronic Australasia Pty Ltd

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

 System Length: 8.00mm-38.0mm

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

 Length: 8.0mm-30.0mm

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

 Coronary Stent System Length: 8.00mm-30.0mm

 Sub-Group 2: General Purpose Bare metal stents

 Abbott Australasia Pty Ltd

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

 Megalink Peripheral Stent; ACS RX

 Herculink Peripheral Stent. Stainless steel

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

AY028 Multilink Coronary Stent System -  Cobalt chrome stent 2.25mm to 4.0mm widths, 8mm $1,248.00

  to 38mm lengths

 Atrium Australia - Pacific Rim Pty Limited

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

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

 expandable Cobalt Chromium stent

 premounted on a rapid exchange system

 Bio Excel Australia Pty Ltd

BE001 Gazelle Coronary Stent Stainless Steel Diam 2.25-4.0mm  Length 8- $1,248.00

 Biotronik Australia Pty Ltd

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

Prostheses List by Category, Groups and Sponsor Page 7 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

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

 tubular, balloon-expandable stent sculpted  available in 66 different

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

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

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

  followed by a transition zone and  premounted on a delivery

 helicoidally arranged struts in the middle.  system which has nominal

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

  next loop by 3 longitudinal struts.  The  2.0mm and 5.0mm.

 stent surface is fully coated with a layer

 of amorphous hydrogen-rich silicon

 carbide (aSiC:H).  This material has

 semiconducting properties that efficiently

 prevent the electron transfer from

 fibrinogen to the metal surface in vitro. 

 Thereby the conversion from fibrinogen

 to fibrin and it's depoisition at the stent

 surface is reduced.  Additionally, aSiC:H -

  coated stents exhibit a lower adhesion

 and activation of blood platelets and

 leucocytes.  Finally, the release of

 potentially allergenic ions from a silicon

 carbide coated stent is substantially

 reduced in comparison to an uncoated

 metal stent3.  This coating is used on all

 Biotronik coronary stents producedso far

 Boston Scientific Australia Pty Ltd

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

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

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

 Imaxeon Pty Ltd

IX001 Amazonia CroCo Balloon expandable intracoronary cobalt  Lengths:  8mm, 12mm, 16mm,  $1,248.00

 chromium stent premounted onto a rapid  20mm, 24mm, 28mm, 32, 36,

 exchange delivery catheter and 40mm.  Diameters: 

 2.25mm, 2.5mm, 2.75mm,

 3.0mm, 3.5mm, 4.0mm, 4.50

 and 5.00 mm in all lengths

 Johnson & Johnson Medical Pty Ltd

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

 heparin coated

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

 8 - 33 mm

Prostheses List by Category, Groups and Sponsor Page 8 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

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

  a balloon delivery system

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

 System Diameter (mm) 8 x 2.50, 2.75,

 3.0, 3.50, 4.0; 12 x 2.50, 2.75,

 3.0, 3.50, 4.0; 17 x 2.50, 2.75,

 3.0, 3.50, 4.0; 24 x 2.75, 3.0,

 3.50, 4.0; 33 x 2.75, 3.0, 3.50,

 Medtronic Australasia Pty Ltd

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

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

 Micro-Driver Stent: diameter

 (2.25 - 2.75mm), length (8 -

MC932 Driver Sprint Coronary Stent System Cobalt Alloy Diameter: 2.25 - 4.5 mm;  $1,248.00

 Length: 8-30mm

MC956 Integrity Coronary Stent System Cobalt Alloy Coronary Stent Diameter: 2.25 - 4.5mm; Length: $1,248.00

  8 - 30mm

 OrbusNeich  Medical Pty Ltd

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

 System Expandable Stent (Tubular) 2.5-4.0mm

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

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

 Terumo Corporation Australia

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

 Length 8mm - 30mm length

 Sub-Group 3: Bare metal stents for specific indications

 a, b

 Abbott Australasia Pty Ltd

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

 c.3

 Imaxeon Pty Ltd

IX003 Minvasys Nile Delta Coronary Stent  Balloon expandable Amazonia  Nile Delta 2.50mm diameter x  $1,248.00

 intracoronary cobalt chromium stent  8mm length; Nile Delta 3.00mm

 premounted onto a rapid exchange  diameter x 8mm length

 delivery catheter with tapered balloon.

Prostheses List by Category, Groups and Sponsor Page 9 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 C1

 Abbott Australasia Pty Ltd

AY027 Multilink Coronary Stent System -  316L Stainless steel stent Length 1.5 - 8.0mm $2,200.00

 C2

 Imaxeon Pty Ltd

IX002 Nile CroCo Intracoronary stent pre-mounted on two  Diameter : 2.50 - 3.50mm.  MB  $1,750.00

 rapid exchange delivery systems for  and 2.00-3.00mm SB

 bifurcation lesions treatment Lengths 18 mm and 24 mm

Group 13: Special Purpose Percutaneous Cardiovascular Devices

 Sub-Group 1: Intracardiac Defect Occluders

 a

 Medtel Australia Pty Ltd

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

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

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

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

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

 and delivery system

ME187 AMPLATZER Duct Occluder II Self expandable multiple Nitinol wire  Waist diameter 3-6mm, Nominal $10,200.00

 mesh PDA occlusion device  length 4-6mm

 Pacing Importers Pty Ltd - Life Systems

PI020 'STARflex Rapid Transport Plus System The STARFlex Rapid Transport Plus  23mm, 28mm, 33mm and  $10,200.00

 System consists of two primary

 components: 1) The device, a permanent

 implant, which is constructed primarily of

  a metal MP35N framework to which

 polyester fabric is attached, and 2) The

 delivery catheter, a Pebax based catheter

 designed specifically to facilitate

 attachment, loading, delivery and

 deployment of the device to the defect.

 The device and delivery catheter can be

 packaged separately or pre-attached as a

 St. Jude Medical Australia Pty Ltd

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

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

Prostheses List by Category, Groups and Sponsor Page 10 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 W L Gore & Associates

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

 consists of an implantable endoprosthesis  35mm

 and a catheter delivery system.  The

 Occluder is comprised of a nickel-

 titanium (Nitinol) wire frame covered

 with expanded polytetrafluoroethylene

 (ePTFE).  The ePTFE is treated with

 Sub-Group 3: Vascular Occlusion Devices

 Denward Dell Pty Ltd TA Surimex

DW001 Nit-Occlud PDA Occlusion System Nitinol spiral coil and delivery system for  Distal x Proximal Coil Diameter:  $1,900.00

 transcatheter occlusion of PDA 4x4mm, 5x4mm, 6x5mm,

 10x6mm, 12x6mm, 14x6mm;

 Introducer Sheath: 4F, 5F;

 Length Introducer: 85cm,

 105cm; Coil Length

 configurated +-0.5mm: 3.5mm,

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

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

 12 x 6mm, 14 x 6mm;

 Introducer Sheath:  5F; Length

 Introducer: 85cm, 105cm; Coil

 Length configurated +-0.5mm:

Group 14: Implantable Cardiac Event Recorders

 Medtronic Australasia Pty Ltd

MC763 Reveal XT Reveal XT Insertable Cardiac Monitor 61 x 19 x 8 mm with a volume  $3,900.00

 of 9cc

MC768 Reveal DX Insertable Cardiac Monitor 61 x 19 x 8 mm with a volume  $3,900.00

 of 9cc

 St. Jude Medical Australia Pty Ltd

SJ152 SJM Confirm Model DM2102 Implantable cardiac monitor with atrial  6.5cc, 12g $3,900.00 Temporary Listing

 fibrillation monitoring.

SJ159 SJM Confirm Model DM2100 Implantable cardiac monitor 6.5cc, 12g $3,900.00 Temporary Listing

Prostheses List by Category, Groups and Sponsor Page 11 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

Group 15: Endovascular Therapeutic Devices

 Sub- Group 2: Embolic Protection Devices

 St. Jude Medical Australia Pty Ltd

SJ127 Proxis Embolic Protection System -  Proximal embolic protection device and  6F and 7F $2,100.00

 Long Sheath delivery system

Group 2 - Cardiothoracic Tissue Valves

 Edwards Lifesciences Pty Ltd

EL032 Baxter Edwards Prima Plus Stentless  Edwards Prima Plus. Porcine Valve;  19mm-29mm $4,841.00

 Bioprosthesis Model 2500P Prosthetic  Woven Polyester Cloth.

 Heart Valve

 Group 2a - Stented

 Medtronic Australasia Pty Ltd

MC950 Mosaic Ultra Cinch II Small Aortic Root Bioprosthesis 19mm - 29mm $4,445.00 $5,650.00

MC962 Mosaic Cinch II Aortic Bioprosthesis 19mm -29mm $4,445.00 $5,345.00

 St. Jude Medical Australia Pty Ltd

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

 for supra-annular placement in the aortic  23mm

 Total Height - 14-16mm

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

 annulus diameter

 14-20 total height

 Mitral Valves 25-33mm tissue

 annulus diameter

 15-20mm total height

Prostheses List by Category, Groups and Sponsor Page 12 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 (p)

 St. Jude Medical Australia Pty Ltd

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

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

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

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

 35mm, Implant Height - 8-

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

 Diameter - 21 - 29mm             

                  Mitral Valves -

 Tissue Annulus Diameter - 25-

 35mm

SJ192 Epic Flexfit Triple-composite Bioprosthetic heart  Aortic Valves 21-29mm tissue  $4,445.00

 annulus diameter, 14-20mm total

  height. Mitral Valves 25-33mm

 tissue annulus diameter, 15-

 20mm total height.

SJ201 Epic FlexFit Supra Triple-composite Bioprosthetic heart  Tissue Annulus Diameter -  $4,445.00

 valve for supra-annular placement in the  19mm-23mm. Total Height

 aortic position

 B (Bovine), E (Equine), P (Porcine)

 Edwards Lifesciences Pty Ltd

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

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

 Bioprosthesis Model 6650 Mitral Valve Alloy; Silicone Rubber,

 Medtronic Australasia Pty Ltd

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

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

 Group 2b - Stented, pericardial

 Edwards Lifesciences Pty Ltd

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

 Magna Mitral Bioprosthesis, Model

 Sorin Group

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

Prostheses List by Category, Groups and Sponsor Page 13 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 (p)  Pericardial

 Edwards Lifesciences Pty Ltd

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

 Magna Ease Bioprosthesis, Model

 B (Bovine), E (Equine), P (Porcine)

 Edwards Lifesciences Pty Ltd

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

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

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

 Perimount Plus Pericardial Bioprosthesis Rubber, Polytetrafluoroethylene

  Mitral - Model 6900P

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

 composition: Glutaraldehyde treated  Valve; 21MM Aortic Pericardial

 bovine pericardium/elgiloy wireform  Tissue Valve; 23MM Aortic

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

 suture ring/polytetrafluoroethylene  Aortic Pericardial Tissue Valve;

 cloth/polyester cloth. 27MM Aortic Pericardial Tissue

 Valve; 29MM Aortic Pericardial

 Tissue Valve

 Group 2c - Non-Stented

 Medtronic Australasia Pty Ltd

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

 St. Jude Medical Australia Pty Ltd

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

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

 Bioimplant Heart Valve Mitral: 27-32mm

 e

 Advanced Biomedical Pty Ltd

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

 Bioprostheseis (non stented)

Prostheses List by Category, Groups and Sponsor Page 14 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

Group 2: Dual Chamber ICD's

 Generation 3

 Guidant Australia Pty Ltd

GU149 Vitality 2 DR - Model T165 Dual Chamber ICD 30cc; 82g $43,680.00

GU150 Vitality 2 EL DR - Model T167 Dual Chamber ICD 30cc; 82g $43,680.00

 Sorin Group

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

 a

 Boston Scientific Australia Pty Ltd

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

 Sorin Group

SA147 Paradym DR 8550 Dual Chamber, High Energy, Implantable  Weight: 90 grams; Volume:  $45,760.00

 Cardioverter Defibrillator with rate  32.6cc; Dimensions: 58.4 x 73.4

 St. Jude Medical Australia Pty Ltd

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

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

 A,C,D

 Medtronic Australasia Pty Ltd

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

 Defibrillator, Dual Chamber

MC938 Virtuoso II DR Model - Implantable Cardioverter  37cc, 68g $45,760.00

 Defibrillator, Dual Chamber

 A,D

 Biotronik Australia Pty Ltd

BT086 Lumax 340 DR-T ICD-DR 34 J with bidirectional Home  One Size Only $45,760.00 $48,760.00

 Monitoring. Dual chamber

BT101 Lumax 540 DR-T High Energy, Dual-Chamber ICD  Diamensions: 66*55*13mm,  $45,760.00 $48,760.00

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

 Advanced Patient Management Via unique

  Home Monitoring Technology

 incorporating Automatic Ventricular

Prostheses List by Category, Groups and Sponsor Page 15 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Boston Scientific Australia Pty Ltd

BS135 Teligen 100 DR DF-1/IS-1 Dual chamber ICD, high energy with RF 31.5cc, 9.9mm $45,760.00

 St. Jude Medical Australia Pty Ltd

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

 with RF Telemetry

SJ144 AnalyST DR Model CD2217-36 Dual Chamber cardioverter defibrillator  80g, 42cm $45,760.00 $47,760.00

 with RF telemetry and ST Segment

 A,D,E

 Boston Scientific Australia Pty Ltd

BS134 TELIGEN 100 HE DR 4-SITE Dual Chamber ICD, high energy with RF  31.55cc, 9.9mm $46,510.00

 c

 Guidant Australia Pty Ltd

GU157 Vitality AVT - Model A155 Dual Chamber ICD with atrial therapies 30cc $43,680.00

 D

 Biotronik Australia Pty Ltd

BT091 Lumax 300 DR-T ICD-DR with bidirectional Home  One size only $43,680.00 $46,680.00

 St. Jude Medical Australia Pty Ltd

SJ215 AnalyST DR CD2217-30 Dual chamber cardioverter defribillator  74g, 38cc $43,680.00 $45,680.00

 with RF telemetry and ST segment

 Generation 4

 a, d, e

 St. Jude Medical Australia Pty Ltd

SJ235 AnalyST Accel DR CD2219-36Q Dual chamber cardioverter defibrillator  80g, 41cc $47,880.00

 with RF telemetry and ST segment

 monitoring and SJ4 connector

SJ239 Current Accel DR CD2215-36Q Dual Chamber Cardioverter Defibrillator  80g, 41cc $47,880.00

 with RF Telemetry and SJ4 connector

 A,C,D

 Medtronic Australasia Pty Ltd

MC814 Secura DR Fully Automatic, Wireless Implantable  37cc $47,130.00

 cardioverter defibrillator with high energy

  capability and therapies for ventricular

 and atrial tachyarrhythmia

Prostheses List by Category, Groups and Sponsor Page 16 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 A,D

 St. Jude Medical Australia Pty Ltd

SJ143 AnalyST Accel DR CD2219-36 Dual Chamber cardioverter defibrillator  80g, 42cc $47,130.00 $48,480.00

 with RF telemetry and ST Segment

SJ153 Current Accel DR RF CD2215-36 Dual Chamber Cardioverter Defibrillator  80g, 42cc $47,130.00 $48,480.00

 with RF Telemetry

 D

 St. Jude Medical Australia Pty Ltd

SJ214 Current Accel DR RF CD2215-30 Dual chamber cardioverter defribillator  74g, 38cc $46,030.00

 with RF telemetry

SJ217 AnalyST Accel DR CD2219-30 Dual Chamber cardioverter defibrillator  74g, 38cc $46,030.00

 with RF telemetry and ST segment

Group 3 - Cardiothoracic Valve Conduits

 Group 3a - Mechanical Valve

 Advanced Biomedical Pty Ltd

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

 graft model 502AG Polyester, Titanium

 Medtronic Australasia Pty Ltd

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

 collagen impregnated conduit Model

 Sorin Group

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

 sterile, CarboSeal Ascending Aortic

 Prosthesis with Handle Model AP21,

 Model AP23, Model AP25, Model AP27,

  Model AP29, Model AP31, Model

 AP33, Carboseal Valsalva

 St. Jude Medical Australia Pty Ltd

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

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

 Prosthesis - VAVGJ sewn into the base of a woven polyester

 fibre graft which has been impregnated

 with bovine-derived gelatin

Prostheses List by Category, Groups and Sponsor Page 17 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Group 3b - Tissue Valve, stented porcine

 Medtronic Australasia Pty Ltd

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

 Model 100/150

Group 3: ICD's with CRT

 Generation 2

 Boston Scientific Australia Pty Ltd

BS129 LIVIAN CRT-D CRT-D with RF 40cc, 79.5g, 14.5mm $45,760.00

 Guidant Australia Pty Ltd

GU147 Contak Renewal 4 CRT-D Model H190,  CRT-D One Size only $45,760.00

 Model H195

 Sorin Group

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

 a

 Boston Scientific Australia Pty Ltd

BS130 LIVIAN CRT-D HE CRT-D, high energy with RF 44cc, 87.5g, 14.5mm $47,840.00

 Guidant Australia Pty Ltd

GU144 Contak Renewal 4 HE CRT-D Model  CRT-D high energy One size only $47,840.00

 H197, Model H199

 Sorin Group

SA145 PARADYM CRT-D 8750 Implantable Cardioverter Defibrillator  34cc,  94 grams;  61.8 x 73.4 x  $47,840.00

 with Cardiac Resynchronisation therapy,  11mm

 High Energy

 St. Jude Medical Australia Pty Ltd

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

 Defibrillator with V-V Timing

 Programmability

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

 Defibrillator

Prostheses List by Category, Groups and Sponsor Page 18 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 A,C

 Guidant Australia Pty Ltd

GU155 Contak Renewal 4 AVT HE CRT - D -  Implantable Cardioverter Defibrillator  40cc; 89g $47,840.00

 Model M177, M179 with cardiac resynchronisation Therapy

 A,C,D

 Medtronic Australasia Pty Ltd

MC720 Concerto CRT-D Implantable Cardioverter Defibrillator  38cc $47,840.00 $50,000.00

 with Cardiac Resynchronisation Therapy

MC937 Concerto II Fully automatic, wireless implantable  38cc $50,000.00

 cardioverter defibrillator with Cardiac

 Resynchronisation Therapy (CRT), and

 therapies for ventricular and atrial

 tachyarrhythmia.

 A,D

 Biotronik Australia Pty Ltd

BT089 Lumax 340 HF-T CRT-D 34 J with bidirectional Home  One Size Only $47,840.00 $53,000.00

 Monitoring

BT102 Lumax 540 HF-T High Energy, Three Chamber ICD  Diamensions: 66*59*13 mm,  $47,840.00 $53,000.00

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

 Advanced Patient Management Via unique

  Home Monitoring Technology

 incorporating Automatic RV/LV

 Threshold Monitoring and Extended

 Boston Scientific Australia Pty Ltd

BS139 COGNIS 100 HE (DF-1/IS-1 & DF- CRT-D high energy with RF 32.5cc, 9.9mm $47,840.00

 St. Jude Medical Australia Pty Ltd

SJ128 Promote RF CRT-D 3213 Cardiac Resynchronisation Therapy  43cc, 82g $47,840.00 $49,840.00

 Defibrillator with RF Telemetry

 A,D,E

 Boston Scientific Australia Pty Ltd

BS138 COGNIS 100 HE 4-SITE CRT-D high energy with RF IS4 32cc, 9.9mm $48,590.00

 c

 Guidant Australia Pty Ltd

GU154 Contak Renewal 4 AVT CRT -D -  Implantable Cardioverter Defibrillator  37cc; 89g $45,760.00

 Model M170 and M175 with Cardiac Resynchronisation Therapy

Prostheses List by Category, Groups and Sponsor Page 19 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 D

 Biotronik Australia Pty Ltd

BT088 Lumax 300 HF-T CRT-D with bidirectional Home  One size only $45,760.00 $48,760.00

 Generation 3

 a, d, e

 St. Jude Medical Australia Pty Ltd

SJ236 Promote Accel CD3215-36Q Cardiac Resynchronisation Therapy  82g, 43cc $52,750.00

 Defibrillator with RF Telemetry and SJ4

 connector

 A,C,D

 Medtronic Australasia Pty Ltd

MC812 Consulta CRT-D Fully Automatic, Wireless Implantable  38cc $52,000.00

 cardioverter defibrillator with cardiac

 resynchronization therapy (CRT), and

 therapies for ventricular and atrial

 tachyarrhythmia

 A,D

 St. Jude Medical Australia Pty Ltd

SJ150 Promote Accel RF CD3215-36 Cardiac Resynchronisation Therapy  82g, 43cc $52,000.00

 Defibrillator with RF Telemetry

 D

 St. Jude Medical Australia Pty Ltd

SJ145 Promote Accel CD3215-30 Cardiac Resyncronisation Therapy  76g, 39cc $49,760.00

 Defibrillator with RF Telemetry

Prostheses List by Category, Groups and Sponsor Page 20 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

Group 4 - Cardiothoracic Atrio-Ventricular Rings and Bands

 Group 4a - Ring, Standard

 Edwards Lifesciences Pty Ltd

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

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

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

 Holder; Mitral Cosgrove-Edwards  Carpentier-Edwards Physio Annuloplasty

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

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

 Polyester Cloth, Cosgrove-Edwards

 Annuloplasty Band. Composition: Silicone

  Rubber; Polyester Cloth. Carpentier-

 Edwards Tricuspid Ring. Composition:

 Titanium Alloy; Silicone Rubber;

 Medtronic Australasia Pty Ltd

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

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

 Ancore Chordal Model 620RG

 Sorin Group

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

 St. Jude Medical Australia Pty Ltd

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

 Group 4b - Ring, with modification

 Edwards Lifesciences Pty Ltd

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

 cloth/plastic template Mitral valve annular  m/34mmd

 repair device designed specifically for

 patients with Ischemic Mitral regurgitation

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

 with Holder

 Medtronic Australasia Pty Ltd

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

 anterior flexibility

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

 physiologic mitral valve shape

Prostheses List by Category, Groups and Sponsor Page 21 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 St. Jude Medical Australia Pty Ltd

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

SJ195 Attune Flexible Adjustable Annuloplasty  Flexible annuloplasty ring 25mm - 43mm $2,200.00

 Ring

 Group 4c - Band, Standard

 Edwards Lifesciences Pty Ltd

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

 System titanium/silicone/polyester velour

 cloth/plastic template

 Group 4d - Band, with modification

 Medtronic Australasia Pty Ltd

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

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

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

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

 includes-band, malleable handle, template

 with suture markers, sizers

 Reid Healthcare

RH002 Kalangos Mitral Ring KALANGOS Mitral Ring is intended for  Diameter 16mm - 36mm, Height $2,200.00 $2,500.00

 heart valve repair. Each device is   10.62mm - 24.61mm

 characterized by a resorbable polymeric  Thickness 1.3mm - 1.5mm

 curved segment, processed in poly-1,4-

 dioxanone, moulded around a PVDF

 suture itself ended by swaged stainless

 steel needles. These three constituents are

  assembled in such a way that they

 cannot be shared or dismounted after

 assembly without irremediably destroying

  the device. For these reasons,

 KALANGOS Mitral Ring should be

 considered as a single device. Each

 extremity of the polymeric segment is

 terminated by a sharp end prolonged by

 the PVDF suture with a swaged stainless

Prostheses List by Category, Groups and Sponsor Page 22 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

RH003 Kalangos Tricuspid Ring KALANGOS Tricuspid Ring is intended  TRK16 5.10 Radius 1 (mm)  $2,200.00 $2,500.00

 for heart valve repair. Each device is  9.31 Radius 2 (mm) 3.1 Radius

 characterized by a resorbable polymeric  3 (mm) 5.44 Height (mm) 1.30

 curved segment, processed in poly-1,4- Thickness (mm)

 dioxanone, moulded around a PVDF  TRK18 6.1 Radius 1 (mm)

 suture itself ended by swaged stainless  10.44 Radius 2 (mm) 4.1 Radius

 steel needles. These three constituents are  3 (mm) 7.98 Height (mm) 1.30

  assembled in such a way that they  Thickness (mm)

 cannot be shared or dismounted after  TRK20 7.1 Radius 1 (mm) 8.92

 assembly without irremediably destroying Radius 2 (mm) 5.1 Radius 3

  the device. For these reasons,  (mm) 8.96 Height (mm) 1.30

 KALANGOS Tricuspid Ring should be  Thickness (mm)

 considered as a single device. Each  TRK22 8.1 Radius 1 (mm) 9.27

 extremity of the polymeric segment is  Radius 2 (mm) 6.1 Radius 3

 terminated by a sharp end prolonged by  (mm) 10.05 Height (mm) 1.30

 the PVDF suture with a swaged stainless  Thickness (mm)

 steel needle on both sides. TRK24 9.1 Radius 1 (mm)

 11.21 Radius 2 (mm) 7.1 Radius

  3 (mm) 10.97 Height (mm)

 1.30 Thickness (mm)

 TRK26 10 Radius 1 (mm) 11.21

  Radius 2 (mm) 8 Radius 3

 (mm) 10.37 Height (mm) 1.50

 Thickness (mm)

 TRK28 10.5 Radius 1 (mm)

 16.71 Radius 2 (mm) 9 Radius 3

  (mm) 11.02 Height (mm) 1.50

 Thickness (mm)

 TRK30 12 Radius 1 (mm) 11.9

 Radius 2 (mm) 10 Radius 3

 (mm) 12.83 Height (mm) 1.50

 Thickness (mm)

 TRK32 13 Radius 1 (mm) 15.45

  Radius 2 (mm) 11 Radius 3

 (mm) 13.15 Height (mm) 1.50

 Thickness (mm)

 TRK34 14 Radius 1 (mm) 16.25

  Radius 2 (mm) 12 Radius 3

 (mm) 13.5 Height (mm) 1.50

 Thickness (mm)

 TRK36 15 Radius 1 (mm) 15.85

  Radius 2 (mm) 13 Radius 3

 (mm) 16.09 Height (mm) 1.50

 Thickness (mm)

Prostheses List by Category, Groups and Sponsor Page 23 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 St. Jude Medical Australia Pty Ltd

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

Group 4: Single Chamber Pacemakers

 Generation 1

 St. Jude Medical Australia Pty Ltd

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

 implantable pacemaker adaptive pacing device with extended

 longevity

 Generation 2

 St. Jude Medical Australia Pty Ltd

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

 implantable pacemaker rate-adaptive pacing devices with

 extended longevity

 Generation 3

 Biotronik Australia Pty Ltd

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

 SSIR pacemaker

BT080 Cylos VR single chamber dual sensor rate responsive one size only $5,928.00

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

 Loop Stimulation (CLS)

BT109 Entovis SR Fully automatic, extended longevity,  53 x 39 x 6.5W x H x D [mm],  $5,928.00

 single cFully automatic, extended  Size 1 [cm3],  25 Mass[g]

 longevity, single chamber pacemaker with

  Closed Loop Stimulation.

BT113 Evia SR Fully automatic, extended longevity,  53 x 39 x 6.5 W x H x D [mm],  $5,928.00

 single chamber pacemaker with Closed  Size 10[cm3], 25 Mass [g]

 Loop Stimulation.

 Boston Scientific Australia Pty Ltd

BS124 Insignia AVT 1192 Single chamber rate responsive  10cc, 23.4g $5,928.00

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

BS147 Altrua 40 SR Single chamber rate responsive  10cc - 15cc $5,928.00

Prostheses List by Category, Groups and Sponsor Page 24 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

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

BS152 Altrua 60 SR Single chamber rate responsive  10cc - 15cc $5,928.00

 Guidant Australia Pty Ltd

GU124 Insignia Entra SR Models 1195 & 1198 Single Chamber Rate Responsive  One size only $5,928.00

 Permanent Pacemaker

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

 Permanent Pacemaker

GU139 Insignia Ultra SR Model 1190 Single Chamber Rate Responsive  One size only $5,928.00

 Medtronic Australasia Pty Ltd

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

 ADSR06, ADSR03

 Sorin Group

SA137 Symphony SR Titanium one size only $5,928.00

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

 with rate response modulation 19 Grams

 7.5 cm3

SA143 ESPRIT SR Single Chamber Permanent Pacemaker  Dimensions: 37.4 x 41.5 x  $5,928.00

 with Rate Response Modulation 6.1mm Weight : 19grams.

 St. Jude Medical Australia Pty Ltd

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

 implantable pacemaker adaptive pacing device

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

 implantable pacemaker rate-adaptive pacing devices with

 extended longevity

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

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

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

SJ205 Accent SR PM 1110 Single Chamber Rate Responsive  18g, 9.5cc $5,928.00

 a

 St. Jude Medical Australia Pty Ltd

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

 2525T Pacemaker

Prostheses List by Category, Groups and Sponsor Page 25 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 D

 Biotronik Australia Pty Ltd

BT108 Entovis SR-T Fully automatic, extended longevity,  53 x 39 x 6.5 W x H x D [mm],  $5,928.00 $8,928.00

 single chamber pacemaker with Closed  Size 11 [cm3], 24 mass[g]

 Loop Stimulation & BIOTRONIK Home

 Monitoring

BT110 Evia SR-T Fully automatic, extended longevity,  53 x 39 x 6.5 W x H x D [mm],  $5,928.00 $8,928.00

 single chamber pacemaker with Closed  Size 11 [cm3], 24 Mass [g]

 Loop Stimulation & BIOTRONIK Home

 Monitoring

 St. Jude Medical Australia Pty Ltd

SJ200 Accent SR RF PM1210 Single Chamber Pacemaker with RF  23g, 12.8cc $5,928.00 $7,928.00

Group 5 - Cardiothoracic Membranes and Patches

 Group 5a - Tissue

 Advanced Biomedical Pty Ltd

AB066 Supple Peri-Guard (10 x 16cm) Model No PC1016SN - 10 x 16 Bovine  10 x 16cm $760.00

 pericardium patch

AB067 Supple Peri-Guard (8 x 14cm) Nodel No PC0814SN - 8 x 14 Bovine  8 x 14cm $700.00

 pericardium patch

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

 pericardium patch

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

 pericardium patch

 Edwards Lifesciences Pty Ltd

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

 Material, Human or Animal Origin,  Pericardium.

 Sterile Pericardial Patch.

 Group 5b - Synthetic, Cardiovascular

 Tag Medical

TM040 Repel - CV Bioresorbable Adhesion Barrier 18cmx13.5cmx137 microns $550.00

 W L Gore & Associates

GT117 Gore-Tex - Cardiovascular Patch ePTFE 0.4mm Thickness 2 x 9cm $240.00

Prostheses List by Category, Groups and Sponsor Page 26 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

GT118 Gore-Tex - Cardiovascular Patch ePTFE 0.4mm - 3 x 6cm $280.00

 0.6mm - 2.5cm x 15cm & 5cm

 x 7.5cm

GT120 Gore-Tex  Cardiovascular Patch ePTFE 0.6mm Thickness 5 x 15cm $521.00

GT121 Gore-Tex Cardiovascular Patch ePTFE 0.6mm Thickness 10 x 15cm $945.00

GT126 Acuseal Cardiovascular Patch Vascular ePTFE 0.5mm Thickness 1 x 9cm; 0.8  $223.00

 x 7.5cm

GT127 Acuseal Cardiovascular Patch Cardiac ePTFE 0.5mm Thickness 3 x 6cm & 5  $270.00

 x 7.5cm

 Group 5c - Synthetic, Non-cardiovascular

 W L Gore & Associates

GT122 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 6 x 12cm $360.00

GT123 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 8 x 16cm $643.00

GT124 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 12 x 12cm $748.00

GT125 Preclude Pericardial Membrane ePTFE 0.1mm Thickness 15 x 20cm $1,455.00

Group 5: Dual Chamber Pacemakers

 Generation 1

 Boston Scientific Australia Pty Ltd

BS123 Insignia AVT 882 Dual chamber VDD pacemaker 10.0cc, 23.5g $5,200.00

BS150 Altrua 50 VDD Dual chamber VDD pacemaker 10cc - 15cc $5,200.00

 St. Jude Medical Australia Pty Ltd

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

 Chamber pacemaker adaptive pacing devices with extended

 longevity

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

 Chamber Pacemaker is an implantable, multi-programmable

 rate-adaptive pacing device with AF

 Generation 2

 Medtronic Australasia Pty Ltd

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

Prostheses List by Category, Groups and Sponsor Page 27 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 St. Jude Medical Australia Pty Ltd

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

 implantable pacemaker adaptive pacing device with extended

 longevity

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

 implantable pacemaker adaptive pacing device with extended

 longevity

 Generation 3

 Biotronik Australia Pty Ltd

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

BT104 Cylos 990 DR Dual-chamber pacemaker with Closed  57* 43* 6mm/28g $9,360.00

 Loop Stimulation (CLS)

BT105 Cylos 990 DR-T Dual-chamber pacemaker with Closed  57*43*6mm/28g $9,360.00 $12,360.00

 Loop Stimulation (CLS) and Biotronik

 Home Monitoring Technology

 Boston Scientific Australia Pty Ltd

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

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

BS146 Altrua 40 DR Dual chamber rate responsive pacemaker 10cc - 15cc $9,360.00

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

BS151 Altrua 60 DR Dual chamber rate responsive pacemaker 10cc - 15cc $9,360.00

 Guidant Australia Pty Ltd

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

 Plus DR Model 1298 Permanent Pacemaker

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

 Permanent Pacemaker

GU140 Insignia Ultra DR Model 1291 Dual Chamber Rate Responsive  One size only $9,360.00

GU141 Insignia Ultra DR Model 1290 Dual Chamber Rate Responsive  One size only $9,360.00

 Sorin Group

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

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

 with Rate Response Modulation Dimensions:41.2 x 41.5 x

Prostheses List by Category, Groups and Sponsor Page 28 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

SA144 ESPRIT DR Dual Chamber Permanent Pacemaker  8cc, Weight: 20grams,  $9,360.00

 with Rate Response Modulation Dimensions:41.2 x 41.5 x

 St. Jude Medical Australia Pty Ltd

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

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

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

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

 5386: 44x52x6mm, 23.5g and

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

 b

 Medtronic Australasia Pty Ltd

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

 chamber pacemaker with Anti-

 Tachycardia functions: DDDRP

MC935 EnRhythm MRI SureScan Model EMDR01, MRI Conditional, Rate  13cc, 22g $11,440.00

 Responsive Dual Chamber Pacemaker

 with Anti-Tachycardia functions and

 D

 Biotronik Australia Pty Ltd

BT071 Philos II DR-T Dual Chamber Rate Responsive with  One size only $9,360.00 $12,360.00

 Home Monitoring

BT079 Cylos DR-T Dual chamber dual sensor rate responsive one size $9,360.00 $12,360.00

  with home monitoring system option

 Generation 4

 Biotronik Australia Pty Ltd

BT111 Entovis DR Fully automatic, extended longevity, Dual  53 x 43 x 6.5W x H x D [mm],  $11,440.00

 Chamber Pacemaker with Closed Loop  Size 11 [cm3], 26 Mass [g]

 stimulation & Vp Suppression

BT112 Evia DR Fully automatic, extended longevity, Dual  53 x 43 x 6.5 W x H x D [mm],  $11,440.00

 Chamber Pacemaker with Closed Loop  Size 11 [cm3], 26 Mass [g]

 stimulation & Vp Suppression.

 Medtronic Australasia Pty Ltd

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

 ADDRS1, ADDRL1, ADDR06, ADDR03

Prostheses List by Category, Groups and Sponsor Page 29 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 St. Jude Medical Australia Pty Ltd

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

 18g, 8.5cc

SJ193 Accent DR PM 2112 Dual Chamber Pacemaker 19g, 10.5cc $11,440.00

 b

 Medtronic Australasia Pty Ltd

MC933 Advisa DR MRI SureScan Model A3DR01 Digital dual chamber  13cc, 22g $11,780.00

 pacemaker with SureScan Technology

 (OAE-DDDR) MR Conditional with MVP

  Mode, Complete Capture Management

 Diagnostic (ACM, RVCM), AT/AF Suite

 Diagnostics and Therapies, OptiVol Fluid

 Status Monitoring, and Therapy Guide

MC934 Advisa DR Model A5DR01 Digital dual chamber  13cc, 22g $11,780.00

 pacemaker (OAE-DDDR)  MVP mode

 with Complete Capture Management

 Diagnostic (ACM, RVCM)  AT/AF Suite

 Diagnostics and Therapies, OptiVol Fluid

 Status Monitoring, and Therapy Guide

 D

 Biotronik Australia Pty Ltd

BT114 Evia DR-T Fully automatic, extended longevity, Dual  53 x 44.5 x 6.5 W x H x D  $11,440.00 $14,440.00

 Chamber Pacemaker with Closed Loop  [mm], Size 12 [cm3], 25 Mass

 stimulation, Vp Suppression and

 BIOTRONIK Home Monitoring

BT115 Entovis DR-T Fully automatic, extended longevity, Dual  53 x 44.5 x 6.5 W x H x D  $11,440.00 $14,440.00

 Chamber Pacemaker with Closed Loop  [mm], Size 12 [cm3], 25 Mass

 stimulation, Vp Suppression and

 BIOTRONIK Home Monitoring

 St. Jude Medical Australia Pty Ltd

SJ196 Accent DR RF PM2212 Dual chamber Pacemaker with RF  236, 12.8cc $11,440.00 $13,440.00

Group 6 - Cardiothoracic Assisted Anastomic Devices

 Medtronic Australasia Pty Ltd

MC680 Spyder Proximal Anastomotic Device 6-clip assembly $590.00

Prostheses List by Category, Groups and Sponsor Page 30 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

Group 6: CRT Pacemakers

 Generation 2

 Guidant Australia Pty Ltd

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

 H140, Model H145

 Medtronic Australasia Pty Ltd

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

 Pacemaker Model 8042

 St. Jude Medical Australia Pty Ltd

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

 Device with AF suppression algorithm -

 Titanum

 D

 Biotronik Australia Pty Ltd

BT085 Stratos LV-T Multiprogrammable Biventricular DDDRV One size only $12,480.00 $15,480.00

  with Home Monitoring

 Generation 3

 St. Jude Medical Australia Pty Ltd

SJ194 Anthem PM3112 CRT Pacemaker Cardiac Resynchronisation Therapy  21g, 11.5cc $13,520.00 $14,560.00

 Pacemaker

 D

 St. Jude Medical Australia Pty Ltd

SJ207 Anthem RF PM3212 CRT Pacemaker with RF telemetry 25g, 13.7cc $13,520.00 $14,560.00

Group 7 - Cardiothoracic Assisted Fixation Devices

 Group 7a Valvular

 Medtronic Australasia Pty Ltd

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

Prostheses List by Category, Groups and Sponsor Page 31 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

 Group 7b Related to anastomosis

 Medtronic Australasia Pty Ltd

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

 9.5mm, 8-pack

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

 9.5mm, 2-Pack

 Group 7c Related to skeletal fixation

 s

 Advanced Biomedical Pty Ltd

AB074 FLEXIGRIP (Various Sizes) Nitinol Sternal Closure Clips - various sizes 20mm - 40mm $80.00 $160.00

Group 7: ICD Leads

 Sub -Group 1: Coronary Sinus Leads

 Medtronic Australasia Pty Ltd

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

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

 Sub -Group 2: Subcutaneous Leads

 Guidant Australia Pty Ltd

GU123 Endotak SQ Array XP Lead Model 0085 Sub-Q Array for high DFT 70cm $4,680.00

 Medtronic Australasia Pty Ltd

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

 Lead Model 6996SQ 41cm, 58cm,

 Sub -Group 5: Transvenous/ Steroid/ Passive  Leads

 Biotronik Australia Pty Ltd

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

  quadripolar ICD lead or 18mm electrode spacing

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

 steroid ICD lead

Prostheses List by Category, Groups and Sponsor Page 32 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

BT119 Linox SMART TD Linox SMART TD is a family of ICD  Length:  Linox SMART TD  $9,360.00

 leads with an active fixation helix.  The  65/16 65cm, Linox SMART TD

 fixation helix is comprised of platinum  65/18 65cm, Linox SMART TD

 75/18 75cm; Lead Body

 Guidant Australia Pty Ltd

GU115 Endotak Reliance Lead Passive Dual Coil 59cm, 64cm, 90cm $9,360.00

GU158 Endotak Reliance SG Passive Passive Single Coil wih GORE ePTFE  54cm - 90cm $9,360.00

 covered coils

GU159 Endotak Reliance G Passive Passive Dual Coil with GORE ePTFE  54cm - 90cm $9,360.00

 covered coils

 Medtronic Australasia Pty Ltd

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

 6944RV/SVC 65cm; Model

 6944RV/SVC 75cm; or Model

 6944RV/SVC 100cm; Medtronic Sprint

 Quattro Lead Model 6944RV/SVC 58cm

 Sorin Group

SA148 ISOLINE 2CT Passive fixation, steroid eluting,  Lead body is 7.8 French  $9,360.00

 intergrated bipolar, dual shock coil  diameter whilst 65cm in length

 St. Jude Medical Australia Pty Ltd

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

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

 Endocardial Defibrillation Leads, 7042 -

 Single Coil, 7050/51 - Integrated Bipolar,

 Dual Coil, 7052 - Integrated Bipolar,

 Single Coil

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

 Steroid Eluting, Endocardial Defibrillation  introducer

 Leads with Optim insulation overlay

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

 steroid eluting, endocardial defibrillation

 leads with Optium insulation overlay

 a

 Boston Scientific Australia Pty Ltd

BS170 Endotak Reliance S 4-SITE Passive fixation single coil defibrillation  50-70cm $9,360.00

 leads & 4-SITE connector.

Prostheses List by Category, Groups and Sponsor Page 33 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

BS180 Endotak Reliance G 4-SITE Passive fixation dual coil defibrillation  50-70cm $9,360.00

 leads with ePTFE covered coils & 4-

 SITE connector

BS181 Endotak Reliance SG 4-SITE Passive fixation single coil defibrillation  50-70 $9,360.00

 leads with ePTFE covered coil & 4-SITE

BS183 Endotak Reliance 4-SITE Passive fixation dual coil defibrillation  50-70cm $9,360.00

 leads with 4-SITE connector

 Sub -Group 6: Transvenous/ Steroid/ Active Leads

 Biotronik Australia Pty Ltd

BT084 Linox SD Fractal coated and steroid electrode,  65, 75cm length, 16, 18mm elec $9,000.00 $9,360.00

 active fixation quadrapolar

BT096 Linox S Active fix RV bipolar fractal coated  65, 75cm length $9,000.00 $9,360.00

 steroid IC lead

BT120 Linox SMART SD Linox SMART SD is a family of ICD  Length:  Linnox SMART SD  $9,000.00

 leads with an active fixation helix for the  60/16 61.2cm; Linnox SMART

 therapy of tachycardia arrhythmia.  The  SD 65/16 65cm;  Linnox

 active fixation helix is comprised of  SMART SD 65/18 65cm;

 Linnox SMART SD 75/18

 Guidant Australia Pty Ltd

GU163 ENDOTAK RELIANCE G Active Active Dual Coil with GORE ePTFE  59-90cm $9,000.00

 covered coils

GU164 ENDOTAK RELIANCE SG Active Active Single coil with GORE ePTFE  59-90cm $9,000.00

 covered coils

 Medtronic Australasia Pty Ltd

MC208 Medtronic Sprint Quattro Secure Lead  Leads, Defibrillator, Implantable, Silicone, 58-100cm $9,000.00

 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 $9,000.00

 Defibrillation Lead

 Sorin Group

SA146 ISOLINE 2CR Active fixation, steroid eluting, integrated  Lead body is 7.8 French  $9,000.00 $9,360.00

 bipolar, dual coil defibrillation lead diameter whilst 65cm in length

 St. Jude Medical Australia Pty Ltd

SJ074 Riata Transvenous tachyarrhythmia  Tri-polar Active - Fixation, Steroid- 60cm, 65cm, 8F introducer $9,000.00 $9,360.00

 Leads Model 1582 Eluting, Single shock Coil

Prostheses List by Category, Groups and Sponsor Page 34 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

SJ075 Riata Transvenous Tachyarrhythmia  Quadripolar, dual-coil, steroid eluting,  One size only $9,000.00 $9,360.00

 Lead Model 1580, Model 1581 active fixation tachyarrhythmia leads

SJ081 Riata i Transvenous Tachyarrhythmia  Active fixation leads, Steroid Eluting,  60cm, 65cm, 75cm, 8F  $9,000.00 $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  $9,000.00 $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 $9,000.00 $9,360.00

 (7002 - Single-Coil) Steroid-Eluting

 Steroid Eluting, Endocardial Defibrillation

SJ122 Riata ST Optim 7020/1/2 and 7030/1 7020/1 - Active fixation, true bipolar,  60, 65 and 75cm length and 7Fr  $9,000.00 $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 $9,000.00 $9,360.00

 coil Steroid-eluting Endocardial

 Defibrillation Leads

 a

 Boston Scientific Australia Pty Ltd

BS174 Endotak Reliance SG 4-SITE Active fixation single coil defibrillation  50-70cm $9,000.00

 leads with ePTFE covered coil & 4-SITE

BS178 Endotak Reliance 4-SITE Active fixation dual coil defibrillation leads 50-70cm $9,000.00

  with 4-SITE connector

BS179 Endotak Reliance S 4-SITE Active fixation single coil defibrillation  50-70mm $9,000.00

 leads & 4-SITE connector

BS182 Endotak Reliance G 4-SITE Active fixation dual coil defibrillation leads 50-70cm $9,000.00

  with ePTFE covered coils & 4-SITE

 connector.

 St. Jude Medical Australia Pty Ltd

SJ230 Durata 7120Q, 7121Q and 7122Q 7120/1Q - Adtive fixation, true bipolar;  52cm, 58cm and 65cm $9,000.00 $9,360.00

 7122Q - Active fixation true bipolar -

 single coil steroid eluting endocardial

 defibrillation leads with Optim insulation

 overlay and SJ4 quadripolar lead

Prostheses List by Category, Groups and Sponsor Page 35 of 866

CARDIO-THORACIC

 Minimum Maximum

Billing Code Product Name Description Size  Benefit  Benefit Notations

SJ233 Riata ST Optim 7020Q, 7021Q, 7022Q 7020/1Q - Active fixation, true bipolar;  52cm, 58cm and 65cm $9,000.00 $9,360.00

 7022Q - Active fixation true bipolar -

 single coil steroid eluting endocardial

 defibrillation leads with Optim insulation

 overlay and SJ4 quadripolar lead

 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

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