The Prostheses List

Private health insurers are required to pay benefits for the products listed on the Prostheses List. Find out what the Prostheses List includes, when we update it, and how to apply to list products on the Prostheses List or change current listings.

What is the Prostheses List?

By law, private health insurers are required to pay a benefit for a product if:

  • the product is on the Prostheses List
  • the patient receives the product as part of hospital treatment or hospital substitute treatment
  • the patient has appropriate health insurance to cover for the treatment
  • a Medicare benefit is payable for a service associated with the use of the product.

Examples of products on the Prostheses List include:

  • hip, knee or shoulder joint replacement devices
  • cardiac implantable electronic devices, like pacemakers and implantable cardioverter defibrillators
  • vascular and cardiac stents
  • human tissue items, like bone or bone fragments, vascular grafts, corneas and heart valves
  • insulin infusion pumps
  • cardiac ablation catheters
  • cardiac remote monitoring systems.

The Prostheses List includes:

  • the billing code for each product
  • a name, description and size(s) of each product listed under the billing code
  • the minimum amount of benefit insurers pay for each product.

We categorise prostheses on the Prostheses List by their function, design, performance, and expected outcomes. See the Prostheses List Groupings.

Find out how we assess products and manage the list by reading the Prostheses List Guide.

For hospitals

You can use the Prostheses List to:

  • keep your systems up to date
  • ensure you are claiming the correct benefit for the product used for or implanted into your patients.

For insurers

You can use the Prostheses List to:

  • keep your systems up to date
  • ensure you are paying the correct benefit.

For applicants

You can use the Prostheses List Management System (PLMS) to apply to:

  • list your product on Prostheses List
  • change the details of an existing Prostheses List code
  • expand or compress the products listed under different codes on the Prostheses List
  • transfer, duplicate or delete a Prostheses List code.

See the Prostheses List Guide for:

  • how to apply
  • what evidence to provide when you apply
  • how we assess products for listing on the Prostheses List
  • application and listing fees.

For aortic valve and cardiac prostheses, also see the Trans-Aortic Valve Implantation Clinical Advisory Group (TAVICAG) Guideline.

Updates and changes

We usually update the Prostheses List every March, July and November.

See our private health insurance circulars for changes to the Prostheses List and updates on prostheses reforms.

Legislation

The Private Health Insurance (Prostheses) Rules is a legislative instrument made under the Private Health Insurance Act 2007.  Schedule of the Private Health Insurance (Prostheses) Rules is known as the Prostheses List.

Contact details

Prostheses List contact

Contact us if you have questions about Prostheses List, Prostheses List Advisory Committee or CAGs.

prostheses [at] health.gov.au

View contact

Last updated: 
22 November 2021

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