Elective Surgery Policy
WorkSafe will pay the reasonable cost of elective surgery required as a result of a work-related injury or illness.
- What is elective surgery?
- When will WorkSafe pay for elective surgery?
- When won’t WorkSafe pay for elective surgery?
- Is prior approval required?
- What information does the WorkSafe Agent require?
- Are there any exceptions?
- What will WorkSafe pay for elective surgery?
- When will WorkSafe pay for a prosthesis?
- Will the WorkSafe Agent require an operation report?
Elective surgery is any form of surgery that is not required in an emergency situation.
Emergency surgery is not covered in this policy.
When will WorkSafe pay for elective surgery?
WorkSafe will pay the reasonable cost of elective surgery:
- where the condition is a result of a work-related injury or illness; and
- which is listed on the Medicare Benefits Schedule (MBS)
When won’t WorkSafe pay for elective surgery?
WorkSafe will not pay for elective surgery:
- where the condition is not a result of work-related injury or illness
- which is not listed on the MBS
- which is part of a clinical trial
- which is performed outside Australia without prior written approval from the WorkSafe Agent
Prior written approval from the WorkSafe agent is required, for elective surgery. All elective surgery requests will be assessed on an individual basis.
The WorkSafe agent will acknowledge an elective surgery request within 5 working days of receipt.
What information does the WorkSafe Agent require?
In order to facilitate a timely decision, the WorkSafe agent requires a written request from the surgeon for elective surgery which includes:
- Name and speciality of surgeon performing the surgery
- Referring medical practitioner
- Brief description and clinical indication for surgery
- Relevant MBS item number(s)
- Anticipated prosthesis details, if required
- Relationship between the surgery and the work-related injury or illness, if known
- Description of previous surgical intervention and injury management, if known
- Anticipated post operative plan e.g. hospital length of stay, rehabilitation, work restrictions
When this information is provided and no further information is required, the WorkSafe agent will advise whether the surgery request has been approved or denied within 10 working days of receiving the request.
WorkSafe will consider requests for elective surgery which are not listed on the MBS as an exception. A medical practitioner at the WorkSafe Agent will review these requests on a case by case basis.
What will WorkSafe pay for elective surgery?
WorkSafe will pay the reasonable cost of elective surgery including:
- Medical practitioners – in accordance with the relevant MBS item number and according to the WorkSafe fee schedule
- Hospital and theatre fees – in accordance with the WorkSafe fee schedule
- Prosthetic items - as listed in the Commonwealth Department of Health and Ageing Prosthesis List
When will WorkSafe pay for a prosthesis?
WorkSafe will pay the reasonable cost of a prosthesis/prostheses for elective surgery which is listed on the Commonwealth Department of Health and Ageing Prosthesis List. However, if the item is designated a ‘gap’ item or is not listed on the Prosthesis List, a written clinical rationale for the use of that specific item will be required from the surgeon, for consideration by a medical practitioner at the WorkSafe agent.
Will the WorkSafe Agent require an operation report?
The WorkSafe agent will require an operation report following elective surgery. The operation report may be obtained from the hospital, the referring medical practitioner or the surgeon.
