Health Insurance (Poly Implant Prosthese MRI) Determination 2012
Health Insurance Act 1973
I, RICHARD BARTLETT, delegate of the Minister for Health, make this Determination under subsection 3C (1) of the Health Insurance Act 1973.
Dated      9th MARCH 2012
RICHARD BARTLETT
FIRST ASSISTANT SECRETARY
MEDICAL BENEFITS DIVISION
DEPARTMENT OF HEALTH AND AGEING
 
Contents
1                              Name of Determination                                                                       3
2                                       Commencement                                                                                  3
3                                       Definitions                                                                                          3
4                              Treatment of relevant services                                                             4
5                              Specification of relevant services                                                        4
6                              Supervision and reporting of relevant services                                     4
7                              Requests for relevant services                                                             5
8                              Limitation on number of services                                                         5
9                              Modifying items                                                                                  5
Schedule                     Relevant services and fees                                                                 6
 
 
  
  
1              Name of Determination
                This Determination is the Health Insurance (Poly Implant Prosthese MRI) Determination 2012.
2              Commencement
                This Determination will be taken to have commenced on 12 March 2012.
3              Definitions
         (1)   In this Determination:
Act means the Health Insurance Act 1973.
MRI means magnetic resonance imaging.
PIP implant means a silicone breast prosthesis manufactured by Poly Implant Prosthese.
relevant provisions means all provisions, relating to professional services or to medical services, of the Act and regulations made under the Act, and the National Health Act 1953 and regulations made under that Act, other than clause 1.2.7 of the diagnostic imaging services table.
Note   Clause 1.2.7 of the diagnostic imaging services table sets out the ‘multiple services rule’, which provides for reductions in the fees for diagnostic imaging services where multiple services are provided to the same patient on the same day, for example 2 or more diagnostic imaging services or one or more R-type diagnostic imaging service and one or more consultation service.  The exclusion of clause 1.2.7 means that the services in the Determination will not be relevant in the application of the multiple services rule.
relevant service means a service specified in an item in Part 1 or Part 2 of the Schedule.
remote location means a place within Australia that is more than 30 kilometres by road from:
                (a)    a hospital that provides a radiology or computed tomography service under the direction of a specialist in the specialty of diagnostic radiology; or
               (b)    a free‑standing radiology or computed tomography facility under the direction of a specialist in the specialty of diagnostic radiology.
Schedule means the schedule to this Determination.
Note   Unless a contrary intention appears, an expression used in this Determination has the same meaning as in the Health Insurance Act 1973 — see section 13 of the Legislative Instruments Act 2003.  Expressions defined in the Health Insurance Act 1973 include:
·                consultant physician
·                diagnostic imaging services table
·                general practitioner
·                item
·                professional service
·                specialist
      (2)    Unless the contrary intention appears, a reference in this Determination to a provision of the Act or the National Health Act 1953 or regulations made under the Act or under the National Health Act 1953 as applied, adopted or incorporated in relation to specifying a matter is a reference to that provision as in force from time to time and any other reference to provisions of an Act or regulations is a reference to those provisions as in force from time to time.
4              Treatment of relevant services
         (1)   A relevant service in Part 1 of the Schedule, provided in accordance with this Determination, is to be treated for the relevant provisions as if:
                (a)    it were both a professional service and a medical service; and
               (b)    there were an item in Group I5 of the diagnostic imaging services table that:
                          (i)    related to the service; and
                         (ii)    specified for the service a fee for each State, being the fee mentioned in the item in the Schedule for the service.
 
         (2)   A relevant service in Part 2 of the Schedule, provided in accordance with this Determination, is to be treated for the relevant provisions as if:
                (a)    it were both a professional service and a medical service; and
               (b)    there were an item in Subgroup 22 of Group I5 of the diagnostic imaging services table that:
                          (i)    related to the service; and
                         (ii)    specified for the service a fee for each State, being the fee mentioned in the item in the Schedule for the service.
Note   For this Determination, an internal Territory is deemed to form part of the State of New South Wales — see subsection 3C (7) of the Act.
5              Specification of relevant services
         (1)   Paragraph 1.2.5(1)(a) of the diagnostic imaging services table shall be taken to have effect as if the relevant services were also specified in that paragraph.
         (2)   Clause 2.5.7 of the diagnostic imaging services table shall be taken to have effect as if the items in Part 1 of the Schedule were also specified in that clause.
6              Supervision and reporting of relevant services
                An item in Part 1 of the Schedule applies only to a service:
                (a)    both:
                        (i)         performed under the professional supervision of a specialist in
                        diagnostic radiology who is available to monitor and influence the conduct and diagnostic quality of the examination, including, if necessary, by personal attendance on the patient; and
                        (ii)        reported by a specialist in diagnostic radiology; or
                (b)    performed:
                        (i)         in an emergency; or
                        (ii)        because of medical necessity, in a remote location.
7              Requests for relevant services
         (1)   An item in Part 1 of the Schedule applies only to a service provided at the request of a specialist, consultant physician or general practitioner.
         (2)   A request must be in writing and specify:
                (a)    that the patient is a person who has or is suspected of having a PIP implant; and
                (b)    whether the patient displays symptoms indicating that the implant has or may have ruptured.
8              Limitation on number of services 
                Items 63501 and 63502 do not apply to the service described in the item if a patient has been provided with the service described in either item in the previous 12 months. 
9              Modifying items
     (1)       Subject to subsections (2), (3) and (4), if item 63498 or 63499 applies to a service in this Determination, the fee specified in the item applies in addition to the fee specified in the other item in this Determination that applies to the service.
     (2)       If 2 or more services described in item 63498 are performed for a person on the same day, the fee specified in that item applies to one of those services only.
     (3)       If 2 or more services described in item 63499 are performed for a person on the same day, the fee specified in that item applies to one of those services only.
     (4)       If:
                (a)    one or more services described in item 63498; and
               (b)    one or more services described in item 63499;
are performed for a person on the same day, the fee specified in item 63498 or item 63499, but not both those items, applies to one of those services only.
Schedule        Relevant services and fees
(section 3)
Part 1
Item
Service
Fee ($)

 
Subgroup  32 – Magnetic resonance imaging – PIP breast implant
 
 

63501
MRI – scan of one or both breasts for the evaluation of implant integrity where:
 
(a) a dedicated breast coil is used; and
(b) the request for the scan identifies that the patient:
(i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and
(ii) the result of the scan confirms a loss of integrity of the implant. (R)
$500.00

63502
MRI – scan of one or both breasts for the evaluation of implant integrity where:
 
(a) a dedicated breast coil is used; and
(b) the request for the scan identifies that the patient:
(i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and
(ii) the result of the scan does not demonstrate a loss of integrity of the implant. (R)
$500.00

63504
MRI – scan of one or both breasts for the evaluation of implant integrity where:
 
(a) a dedicated breast coil is used; and
(b) the request for the scan identifies that the patient:
(i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and
(ii) presents with symptoms where implant rupture is suspected; and
(iii) the result of the scan confirms a loss of integrity of the implant. (R)
$500.00

63505
MRI – scan of one or both breasts for the evaluation of implant integrity where:
 
(a) a dedicated breast coil is used; and
(b) the request for the scan identifies that the patient:
(i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and
(ii) presents with symptoms where implant rupture is suspected; and
(iii) the result of the scan does not demonstrate a loss of integrity of the implant. (R)
$500.00

Part 2
 
Item
Service
Fee ($)

63498
MRI service to which item 63501, 63502, 63504 or 63505 applies if:
(a) the service is performed in accordance with sections 6 – 8 of this Determination; and
(b) the service is performed on a person using intravenous or intra muscular sedation
 
$44.80

63499
MRI service to which item 63501, 63502, 63504 or 63505 applies if:
(a) the service is performed in accordance with sections 6 – 8 of this Determination; and
(b) the service is performed on a person under anaesthetic in the presence of a medical practitioner who is qualified to perform an anaesthetic
$156.80