Surgically Implanted Prostheses Policy

POLICY

WorkSafe can pay the reasonable costs of surgically implanted (internal) prostheses required during surgical procedures performed in a private hospital to treat an injured worker’s work-related injury or illness where that prosthesis is listed on the Department of Health and Ageing Prostheses List.

Background
What are surgically implanted prostheses?
The Prostheses List
When can the VWA pay for prostheses?
When the VWA cannot pay for prostheses
How much will the VWA pay?
When is prior approval required?
What happens if prior approval is not sought from the WorkSafe Agent?
What will the VWA pay for in an emergency situation?
What information does the WorkSafe Agent require?
What are the invoicing requirements?

Background
WorkSafe can pay the reasonable cost of prostheses used during surgery for a work-related injury or illness in accordance with section 99of the Accident Compensation Act 1985.

What are surgically implanted prostheses?
A surgically implanted prosthesis is an item of equipment or a device used by a surgeon during a procedure. Items include, but are not limited to, screws, plates, nails and human tissue. External prosthetic limbs, orthotics or other such devices are not considered surgically implanted prostheses.

The Prostheses List

The Prostheses List is maintained by the Department of health and Ageing (DoHA) and lists the Medicare benefit payable for surgically implanted prostheses, human tissue items and other medical devices used during surgery.

Products on the Prostheses List include, but are not limited to, items for hip and knee replacements, screws, plates, nails, human tissue and implantable stimulators and pumps. External limbs, orthotics or other such devices are not included.

The Government, together with a panel of doctors and other health specialists have evaluated prostheses available in Australia and determined which ones are clinically comparable. The evidence shows that the most expensive prostheses are not necessarily the most appropriate ones.

There are 9,500 products on the Prostheses List which are divided into two categories based on the Medicare benefit payable:

ostheses are items listed with a single benefit and are the standard quality available. For each Medicare Benefit Schedule (MBS) item, the Prostheses List aims to have at least one no-gap prosthesis available.

Gap-permitted prostheses

Gap-permitted prostheses have both a minimum and maximum MBS benefit listed. Gap-permitted items have no proven improved clinical outcomes in comparison with no-gap items. WorkSafe therefore requires clinical justification if a gap-permitted prosthesis is intended to be used.

When can WorkSafe pay for internal prostheses?

WorkSafe cannot pay for prostheses:

which are not related to the worker's work-related injury or illness
where the associated surgical procedure has not been approved by the WorkSafe Agent
that are listed as gap-permitted prostheses where there is no adequate clinical justification for use
that are not listed on the Prostheses List, and
where the cost of the device is included in the hospital bed fee, i.e. for public hospitals.

When WorkSafe cannot pay for internal prostheses

WorkSafe cannot pay for prostheses:

which are not related to the worker's work-related injury or illness
where the associated surgical procedure has not been approved by the WorkSafe Agent
that are listed as gap-permitted prostheses where there is no adequate clinical justification for use
that are not listed on the Prostheses List, and
where the cost of the device is included in the hospital bed fee, i.e. for public hospitals.

When is prior approval required?

Prior written approval from the WorkSafe Agent is required for injured worker admission to hospital for elective surgery. The use of no-gap Prosthesis List prostheses will be considered as part of this approval process (see also the Elective Surgery Policy).

For surgical procedures that propose the use of agap-permitted or a prosthesis not listed on the Prosthesis List, surgeonsmust seek prior approval of payment from the WorkSafe Agent by providing written clinical rationale. These requests will be reviewed by a Medical Advisor at the Agent.

What information does the WorkSafe Agent require?

If a treating registered medical practitioner, surgeon or treating specialist believes that a surgically implanted gap-permitted prosthesis is necessary, the following information is required:

clinical justification for the use of a gap-permitted prosthesis in place of a standard no-gap prosthesis
prosthesis supply code and description, and
cost of the prosthesis.

Prostheses will be considered as part of the elective surgery approval process.

What happens if prior approval is not sought from the WorkSafe Agent?

All requests for elective surgery, including surgically implanted prostheses, require prior approval.

If a 'gap permitted' prosthesis or an item not listed on the Prostheses List is used prior to approval, the invoice will be reviewed by the WorkSafe Agent. The prescribing surgeon and/or hospital will be contacted to discuss the use of this item. Payment of the reasonable costs of the gap-permitted or non-listed item may be denied or paid at a lower rate based on a comparable item as listed on the Prostheses List.

How much can WorkSafe pay?

WorkSafe can pay for prostheses required as part of an injured worker's surgery for a work-related injury or illness in accordance with the Prostheses List.

WorkSafe will pay the minimum listed price for a 'no gap' item currently listed in the Department of Health and Ageing Prostheses List.

WorkSafe can pay for no-gap prostheses in accordance with the Prostheses List. WorkSafe will consider paying for gap-permitted or non-listed prostheses on a case by case basis. The WorkSafe Agent will consider recommendations provided by DoHA and comparable listed items when determining the reasonable costs of a gap permitted or non-listed prosthesis.

What can WorkSafe pay for a prosthesis used in an emergency situation?

In emergency situations an item listed on the Prostheses List may be used at the surgeon's discretion. However, where gap-permitted or prostheses not listed on the Prostheses List are used, clinical justification must be provided to the WorkSafe Agent as soon as possible after admission in order to validate WorkSafe's payment of the reasonable costs of such items.

What are the Invoicing Requirements?

To facilitate prompt payment of accounts, invoices must include the following:

Invoice and hospital details
Invoice number
Date of invoice
Hospital name, address and provider number

Worker's details
Name and address
Claim number
Date of birth

Admission and treatment details
Date of service - including admission and discharge dates
ICD-AM-10 v5 diagnosis codes and description
MBS procedure codes - description of surgery
Theatre band (NPBC and APHA)
Prostheses codes - description and cost including whether the item is listed on the Prostheses List or is a 'gap- permitted' item
Consumables and disposables
WorkSafe accommodation classification
Itemised list of discharge medications
Description of the service(s) and fee(s) charged.

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