PNV - Banter and General Comments, page-8550

PolyNovo has had two new sizes of BTM added this month to the Australian Prostheses List.

The stated purpose of the Prostheses List is to ensure that the 45% of Australians who have private hospital cover have access to clinically effective prostheses that meet their health care needs.

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.

Device manufacturers must apply to have products added to the list and provide clinical and economic evidence to support product inclusion. The list is updated three times a year with the November list effective from December 1.

The Prostheses List specifies the minimum amount of benefit that the health insurer must pay for the device. “Similar” devices are allocated the same benefit payment.

In March 2019, the 10cm x 10cm and 10cm x 20cm BTM products were added to the Prostheses List, with the benefits payable set at $1112 and $1697 respectively.

The newly listed sizes are 5cm x 5cm and 25cm x 20cm, with the benefits payable set at $877 and $3296 respectively.

So, for example, if a 5 x 5cm sheet of BTM was used in the treatment of an ulcer or skin cancer excision for a patient with private health cover, it has been possible until now for private health funds to deny payment. From December 1 they will be compelled by law to pay.

The inclusion of the new sized products on the Prostheses List should assist PolyNovo’s ambition to grow the use of BTM in non-burns indications in Australia.

https://www.health.gov.au/health-topics/private-health-insurance/the-prostheses-list