Prosthesis Guidelines for Private Hospitals

The Victorian WorkCover Authority (VWA) considers it reasonable to pay for prostheses required during a surgical procedure performed in a private hospital to treat an injured worker’s work-related injury or illness.

Background
What are prostheses?
When will the VWA pay for prostheses?
When won’t the VWA pay for prostheses?
How much will the VWA pay?
What is the criteria for Emergency Situations?
Is prior approval required?
Are there any exceptions?
What information does the WorkCover Agent require?

Background
The VWA currently meets the cost of prostheses used during surgery in accordance with reasonable cost requirements in S99 of the Accident Compensation Act 1985.

The current arrangements for listing and providing benefits for prostheses used during surgery in private hospitals under the National Health Act 1953 and the Health Insurance Act 1973 came into effect on 31 October 2005. These arrangements have been adopted as the standard by the Private Health Industry and are supported by the Federal Government.

The Prostheses List arrangements are overseen by a panel of experts, including clinicians and economists, who provide some assurances about the safety and cost effectiveness of items listed on the Prostheses Lists. The lists now incorporate benefit levels negotiated on behalf of the industry and represent reasonable costs for health insurers and the VWA. Each listed item is linked to items on the Medicare Benefits Schedules with its associated service descriptions and business rules. The arrangements set the industry standard and benchmark for reasonable cost of prostheses items.

These arrangements for prostheses provide the VWA with the best available evidence basis for approving and funding the reasonable cost of prosthesis for injured workers with an entitlement to compensation because they are widely accepted by industry.

The VWA has adopted as policy the current Prostheses List arrangements, specifically the listing of surgically implanted prostheses, human tissue items and other medical devices, and setting of benefits, as advised by the Department of Health and Ageing (DoHA).

What are prostheses?
Prostheses are medical devices and products that may be required for a surgical procedure. They include but are not limited to screws, plates, nails, and human tissue. They do not include external limbs, orthotics or other such devices.

The DoHA releases a Prosthesis List which lists more than 9,000 prostheses and human tissue products that attract health funds benefits and the amount of benefit to be paid. This list is regularly updated by the DHoA .

When will the VWA pay for prostheses?
The VWA will reimburse private hospitals for the reasonable cost of prostheses:

which are required by an injured worker as a result of a work-related injury or illness; and
where the associated surgical procedure has been approved by the WorkCover Agent; and
when the prostheses are listed on and provided in accordance with the Commonwealth DoHA Prosthesis List.

When won’t the VWA pay for prostheses?
The VWA will not pay for prostheses:

which are not related to the worker’s work-related injury or illness;
where the associated surgical procedure has not been approved by the WorkCover Agent; or
which are not listed on or provided in accordance with the DoHA Prosthesis List.

How much will the VWA pay?
The VWA will pay up to the maximum listed price for ‘no-gap’ and ‘gap’ Prostheses items currently listed on the DoHA Prosthesis List.

Surgeons are required to provide the WorkCover Agent with a written clinical rationale for use of a ‘gap’ item over a ‘no gap’ item, as part of the elective surgery request process.
Prostheses items not listed on the current DoHA Prostheses List will be considered by the WorkCover Agent on a case by case basis. The WorkCover Agent will consider recommendations provided by DoHA and comparable listed items, when determining the reasonable cost of an unlisted Prosthesis item.

See also:
• Are there any exceptions?

What is the criteria for Emergency Situations?
In emergency situations ‘gap’ and ‘no gap’ designated prosthesis list items may be used at the medical specialists discretion. However clinical justification will be required by the WorkCover Agent to validate the charge for ‘gap’ items in some emergency situations.

Is prior approval required?
Prior written approval from the WorkCover Agent is required for admission to hospital for elective surgery. All requests will be assessed on an individual basis. Prostheses will be considered as part of this approval process (see also the VWA Elective Surgery Policy).

Are there any exceptions?
The VWA may consider requests for prostheses that are not listed on or provided in accordance with the Prostheses List. The WorkCover Agent may review these requests on a case by case basis.

What information does the WorkCover Agent require?
The hospital invoice must include an itemised account of the prostheses items.

Prostheses product information may be required to assist WorkCover Agents to determine liability and the reasonable cost of surgery (Section 99(2)(c)(iii) of the Accident Compensation Act 1985). This product information may be required prior to admission and include prostheses item codes and descriptions. Surgeons may be asked to provide this information to the WorkCover Agent.

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