Health Insurance (Photodynamic Therapy) Determination HS/03/2006
__________________________________________________________________
I, TONY ABBOTT, Minister for Health and Ageing, make this Determination under subsection 3C (1) of the Health Insurance Act 1973.
Dated                30/10/2006

 
________Tony Abbott__________
Minister for Health and Ageing
 
 
 
 
 
 
Contents
 
1.           Name of Determination                                                                             3
2.           Commencement                                                                                      3
3.           Interpretation                                                                                           3
4.           Treatment of a relevant service                                                                  3
5.           Circumstances where this Determination applies                                        3
6.           Indexation of Fees                                                                                   4
Schedule       Specified health services                                                              5
 
 

1.                      Name of Determination
This Determination is the Health Insurance (Photodynamic Therapy) Determination HS/03/2006.
2.                      Commencement
This Determination is taken to have commenced on 1 June 2005.
3.                      Interpretation
(1)        In this Determination:
relevant service means a health service, as defined in subsection 3C(8) of the Act, that is specified in the Schedule.
the Act means the Health Insurance Act 1973.
the Schedule means the Schedule to this Determination
Note          Unless the contrary intention appears, expressions used in this Determination have the same meanings as in the Act—see section 13 of the Legislative Instruments Act 2003.
(2)        Unless the contrary intention appears, in this Determination a reference to a provision of the Act or the National Health Act 1953 or regulations made under the Act or under the National Health Act 1953 as applied, adopted or incorporated in relation to specifying a matter is a reference to those provisions as in force from time to time and any other reference to provisions of an Act or regulations is a reference to those provisions as in force from time to time.
4.                      Treatment of a relevant service
A relevant service shall be treated as if:
(a)                    it were both a professional service and a medical service for the purposes of the provisions of the Act, the National Health Act 1953, the Health Insurance Regulations 1975 and the National Health Regulations 1954 that make provision in respect of professional services or medical services; and
(b)                   there were an item in the general medical services table that related to the relevant service and specified in respect of the service a fee in relation to a State, being the fee specified in column 3, column 4 or column 5 of the Schedule in relation to the State specified.
5.                      Circumstances where this Determination applies
This Determination applies:
(a)                    to the first 15 occasions on which a relevant service is rendered to a patient, regardless of when the service has been rendered to the patient; and
(b)                   if the patient is diagnosed with:
(i)                      predominantly classic (>50%) subfoveal choroidal neovascularisation secondary to macular degeneration; and
(ii)                     a baseline best-corrected visual acuity equal to or better than 6/60 (20/200); and
(c)                    for items 42875, 42878 and 42881 of the Schedule – if the diagnosis referred to in paragraph (b) is confirmed by a specialist panel nominated by the Royal Australian and New Zealand College of Ophthalmologists; and
(d)                   for item 42990 of the Schedule – if the diagnosis referred to in paragraph (b) is confirmed or reconfirmed by a specialist panel nominated by the Royal Australian and New Zealand College of Ophthalmologists subsequent to the rendering of:
(i)                      if the diagnosis is confirmed – the relevant service to which item 42875 of the Schedule relates; or
(ii)                     if the diagnosis is reconfirmed – the relevant service to which item 42887 of the Schedule relates; and
(e)                    for item 42999 of the Schedule – if the diagnosis referred to in paragraph (b) is confirmed or reconfirmed by a specialist panel nominated by the Royal Australian and New Zealand College of Ophthalmologists subsequent to the rendering of:
(i)                      if the diagnosis is confirmed – the relevant service to which item 42878 of the Schedule relates; or
(ii)                     if the diagnosis is reconfirmed – the relevant service to which item 42996 of the Schedule relates.
6.                      Indexation of Fees
(1)        The fee specified in Column 3 of the Schedule for a relevant service applies where the service is rendered to a patient after 31 May 2005 and before 1 November 2005.
(2)        The fee specified in Column 4 of the Schedule for a relevant service applies where the service is rendered to a patient after 31 October 2005 and before 1 November 2006.
(3)        The fee specified in Column 5 of the Schedule for a relevant service applies where the service is rendered to a patient after 31 October 2006.
 
 
Schedule        Specified health services
 
 
 
 
 
 

 Column 1 – Item
Column 2 - Health Service
Column 3 – Fee for all States
Column 4 – Fee for all States
Column 5 – Fee for all States

42875
Photodynamic therapy, first treatment on or after 1 June 2002, one eye, for patients having commenced therapy prior to 1 June 2002 (including the infusion of verteporfin continuously through a peripheral vein), using a non-thermal laser at a wavelength of 689nm, other than a service to which item 42887 applies.
$386.15
$393.85
$402.10

42878
Photodynamic therapy, first treatment on or after 1 June 2002, both eyes, for patients having commenced therapy prior to 1 June 2002 (including the infusion of verteporfin continuously through a peripheral vein), using a non-thermal laser at a wavelength of 689nm, other than a service to which item 42996 applies.
$463.40
$472.65
$482.60

42881
Photodynamic therapy, initial treatment, one eye, for patients commencing therapy after 1 June 2002 (including the infusion of verteporfin continuously through a peripheral vein), using a non-thermal laser at a wavelength of 689nm.
$386.15
$393.85
$402.10

42884
Photodynamic therapy, 2nd to 4th treatments on the same eye, where it has been demonstrated that the patient is eligible for further treatments subsequent to a service to which item 42875, 42878 or 42881 applies (including the infusion of verteporfin continuously through a peripheral vein), using a non-thermal laser at a wavelength of 689nm.
$386.15
$393.85
$402.10

42887
Photodynamic therapy, 5th treatment on the same eye (including the infusion of verteporfin continuously through a peripheral vein) using a non-thermal laser at a wavelength of 689nm.
$386.15
$393.85
$402.10

42990
Photodynamic therapy, 6th to 10th treatments on the same eye, where it has been demonstrated that the patient is eligible for further treatments subsequent to a service to which item 42875 or 42887 applies (including the infusion of verteporfin continuously through a peripheral vein), using a non-thermal laser at a wavelength of 689nm.
$386.15
$393.85
$402.10

42991
Photodynamic therapy, 11th to 15th treatments on the same eye, where it has been demonstrated that the patient is eligible for further treatments subsequent to a service to which item 42990 applies (including the infusion of verteporfin continuously through a peripheral vein), using a non-thermal laser at a wavelength of 689nm.
 Not Applicable
$393.85
$402.10

 
 
 
Column 1 – Item
Column 2 - Health Service
Column 3 – Fee for all States
Column 4 – Fee for all States
Column 5 – Fee for all States

42993
Photodynamic therapy, 2nd to 4th treatments on both eyes, where it has been demonstrated that the patient is eligible for further treatments on both eyes subsequent to a service to which item 42875, 42878 or 42881 applies (including the infusion of verteporfin continuously through a peripheral vein), using a non-thermal laser at a wavelength of 689nm.
$463.40
$472.65
$482.60

42996
Photodynamic therapy, 5th treatment on both eyes (including the infusion of verteporfin continuously through a peripheral vein) using a non-thermal laser at a wavelength of 689nm.
$463.40
$472.65
$482.60

42999
Photodynamic therapy, 6th to 10th treatments on both eyes, where it has been demonstrated that the patient is eligible for further treatments on both eyes subsequent to a service to which item 42878 or 42996 applies (including the infusion of verteporfin continuously through a peripheral vein), using a non-thermal laser at a wavelength of 689nm.
$463.40
$472.65
$482.60

43000
Photodynamic therapy, 11th to 15th treatments on both eyes, where it has been demonstrated that the patient is eligible for further treatments on both eyes subsequent to a service to which item 42999 applies (including the infusion of verteporfin continuously through a peripheral vein), using a non-thermal laser at a wavelength of 689nm.
 Not Applicable
$472.65
$482.60

43002
Infusion of verteporfin for discontinued photodynamic therapy, where the session of therapy has been discontinued on medical grounds.
$75.10
$76.60
$78.20

Note    Section 3C (7) of the Act deems an internal Territory to form part of the State of New South Wales.