From the July 2025 PL, the “maximum 3 for each” will be removed from the condition for reimbursement for surgical guides and biomodels. This means that while the limit of 6 benefits per episode of care still applies, these benefits could be claimed in any combination equating to 6 in total. For example:
- 5 surgical guides + 1 biomodel
- 6 surgical guides
- 4 surgical guides + 2 biomodels
- 6 biomodels
The amended condition states:
Prescribed List reimbursement is restricted to the use of the device in craniomaxillofacial surgery procedures involving insertion of an implantable medical device, where that implantable device is listed in either sub-category 07.01 - Craniomaxillofacial Reconstruction & Fixation, or 07.02 – Craniomaxillofacial Implants, or 07.04 – Distractor Systems of Schedule 1, or sub-category 07.03 - Dental Implants, but only if the implantable dental medical device is explicitly identified in the product name or description of the billing code for the surgical guide or biomodel and is used in hospital.
Not limiting the above, for a claim for any implantation procedure (defined by the respective MBS items stated in the claim) for a patient, the Prescribed List reimbursement is limited to 6 PL benefits for any billing codes for surgical guides and/or biomodels, which have been used in an implantation procedure for a patient. This restriction is not impacted by the number of devices implanted during the procedure, for which claim has been submitted.
We have decided to make this change as per our commitment to monitor the impact of the condition. It takes into consideration stakeholder feedback and input from clinicians.
Please note the condition only restricts what private health insurers are obliged to reimburse.
The condition does not restrict:
- the number of surgical guides or biomodels that can be used in a procedure. i.e. if more than 6 surgical guides and/or biomodels are required they can be used.
- the use of surgical guides and biomodels in procedures outside of craniomaxillofacial surgery. They can be used in any procedure required.
- insurers from considering ex gratia payments when more than 6 surgical guides and/or biomodels are clinically required.
Stage 2 of the post-listing review of surgical guides and biomodels is ongoing.
We will continue monitoring the impact of the condition.