The Prostheses List

As of 1 July 2023, the information on this webpage may be out of date. We are working on updating it and will send out a PHI circular when the update is complete.

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

We are moving applications to the Health Products Portal (HPP).

Applications to list new medical devices and human tissue products and to amend current listings can now be submitted through the HPP.

Find more information online.

We are currently reviewing the Prescribed List Guide. In the meantime, please view the Prescribed List application training presentation and a draft version of the Prescribed List Guide for guidance on application requirements. When referring to the draft version of the Prescribed List Guide, stakeholders should note that this is a draft only that will be further amended and edited.

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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