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, changes and reforms
We usually update the Prostheses List every March, July and November.
The Australian Government has also committed $22 million to reforming the list by 2025. We are working with insurers, hospitals, medical device companies and clinicians to make the list more efficient, more transparent and better able to keep up with technological advances.
See our private health insurance circulars for changes to the 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.
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