We are issuing further clarification concerning the Private Health Insurance (Medical Devices and Human Tissue Products) Rules (No. 2) 2023. Specifically for the new condition placed on the billing codes for the surgical guides and biomodels listed in Plastic and Reconstructive category (in subgroups 07.02.02.04, 07.02.05.07, 07.02.06.06, 07.02.07.05 and group 07.02.09).
The condition’s rationale and intent have been included in the Explanatory Statement for the MDHTP Rules, this PHI Circular provides further clarification.
The intent of the condition
The PL reimbursement for surgical guides and biomodels is restricted to the procedures when these devices are used during the implantation/insertion of one of the implantable devices listed in any of the groups or sub-groups of the categories 07.01 - Craniomaxillofacial Reconstruction & Fixation or 07.02 - Craniomaxillofacial Implants. The PL reimbursement does not apply when surgical guides or biomodels are used for any procedures associated with implantation of a device not listed on the PL, or listed in other PL categories or sub-categories, or procedures that do not involve any implantation of a device or a product.
In respect to maximum number of 3 surgical guides or biomodels, the meaning is that for any claims for the implantation procedures (defined by the respective MBS items stated in the claims) for a patient, insurers are not mandated to pay more than 3 PL benefits for any billing codes for surgical guides or biomodels, or no more than 6 benefits if both surgical guides and biomodels (maximum 3 for each) have been used in an implantation procedure for a patient. This restriction is not impacted by a number of devices implanted during a procedure.
The department will continue seeking expert advice and work with stakeholders on further clarification of the meaning and intent of this condition and any other conditions placed or proposed to be placed on the Prescribed List billing codes as required.