{"id":"F2018L01670","name":"Health Insurance (Section 3C General Medical Services –Transcatheter Aortic Valve Implantation) Determination 2018","slug":"health-insurance-section-3c-general-medical-services-transcatheter-aortic-valve-implantation-determi","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":98316,"registerId":"commonwealth-F2018L01670-current","compilationNumber":null,"startDate":"2026-04-02","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Contents","sectionType":"subdivision","heading":"Contents","content":"#### Contents\n\n1. Name 1\n\n3. Authority 1\n\n5. Definitions 1\n\n6. Treatment of relevant services 3\n\n7. Application of items 38495, 38514 and 38522 3\n\n8. Meaning of symbol (H) 3\n\n9. Indexation 3\n\nSchedule 1 – relevant services 4\n\nEndnotes 7\n\nEndnote 1—About the endnotes 7\n\nEndnote 2—Abbreviation key 8\n\nEndnote 3—Legislation history 9\n\nEndnote 4—Amendment history 11","sortOrder":0},{"sectionNumber":"1. Name","sectionType":"part","heading":"1. Name","content":"# 1. Name\n\nThis Determination is the Health Insurance (Section 3C General Medical Services –Transcatheter Aortic Valve Implantation) Determination 2018.","sortOrder":1},{"sectionNumber":"3. Authority","sectionType":"part","heading":"3. Authority","content":"# 3. Authority\n\nThis Determination is made under subsection 3C(1) of the Health Insurance Act 1973.","sortOrder":2},{"sectionNumber":"5. Definitions","sectionType":"part","heading":"5. Definitions","content":"# 5. Definitions\n\n(1) In this Determination:\n\nAct means the Health Insurance Act 1973.\n\nAttendance means undertaking all of the following activities in relation to a TAVI Case Conference:\n\n(a) retaining a record of the day the conference was held, and the times the conference started and ended;\n\n(b) retaining a record of the names of the participants;\n\n(c) provision of expertise to inform the recommendation resulting from the case conference;\n\n(d) retaining a record of the recommendation resulting from the conference.\n\nCoordination means undertaking all of the following activities in relation to a TAVI Case Conference:\n\n(a) ensuring that the patient is aware of the purpose and nature of the patient’s TAVI Case Conference and has consented to their TAVI Case Conference;\n\n(b) recording the day the conference was held, and the times the conference started and ended;\n\n(c) recording the names of the participants of the conference;\n\n(d) provision of expertise to inform the recommendation resulting from the case conference;\n\n(e) recording minutes of the TAVI Case Conference including the recommendation resulting from the conference;\n\n(f) ensuring that the patient is aware of the recommendation.\n\nrelevant provisions means all provisions, of the Act and regulations made under the Act, and the National Health Act 1953 and regulations made under the National Health Act 1953, relating to medical services, professional services or items.\n\nrelevant service means a health service, as defined in subsection 3C(8) of the Act, that is specified in a Schedule.\n\nSchedule means a Schedule to this Determination.\n\nTAVI means Transcatheter Aortic Valve Implantation.\n\nTAVI Case Conference means a process by which:\n\n(a) there is a team of 3 or more participants, where:\n\n(i) the first participant is a cardiothoracic surgeon; and\n\n(ii) the second participant is an interventional cardiologist; and\n\n(iii) the third participant is a specialist or consultant physician who does not perform a service described in item 38495, 38514 or 38522 for the patient being assessed; and\n\n(iv) either the first or the second participant is also a TAVI Practitioner; and\n\n(b) the team assesses a patient’s risk and technical suitability to receive the service described in item 38495, 38514 or 38522, taking into account matters such as:\n\n(i) the patient’s risk and technical suitability for a surgical aortic valve replacement; and\n\n(ii) the patient’s cognitive function and frailty; and\n\n(c) the result of the assessment is that the team makes a recommendation about whether or not the patient is suitable to receive the service described in item 38495, 38514 or 38522; and\n\n(d) the particulars of the assessment and recommendation are recorded in writing.\n\nTAVI Hospital means a hospital, as defined by subsection 121‑5(5) of the Private Health Insurance Act 2007, that is clinically accepted as being a suitable hospital in which the service described in item 38495, 38514 or 38522 may be performed.\n\nTAVI Patient means a patient who, as a result of a TAVI Case Conference, has been assessed as having a high, intermediate or low risk for open surgical aortic valve replacement and is recommended as being suitable to receive the service described in item 38495, 38514 or 38522.\n\nTAVI Practitioner means a cardiothoracic surgeon or interventional cardiologist who is accredited by the Cardiac Accreditation Services Limited.\n\nNote: The following terms are defined in subsection 3(1) of the Act:\n\n clinically relevant service\n\n general medical services table\n\n item\n\n practitioner\n\n professional service\n\n(2) Unless the contrary intention appears, a reference in this Determination to a provision of the Act or the National Health Act 1953 or regulations made under the Act or under the National Health Act 1953 as applied, adopted or incorporated in relation to specifying a matter is a reference to those provisions as in force from time to time and any other reference to provisions of an Act or regulations is a reference to those provisions as in force from time to time.","sortOrder":3},{"sectionNumber":"6. Treatment of relevant services","sectionType":"part","heading":"6. Treatment of relevant services","content":"# 6. Treatment of relevant services\n\nFor subsection 3C(1) of the Act a relevant service specified in Schedule 1 to this Determination, provided in accordance with this Determination and as a clinically relevant service, is to be treated, for the relevant provisions, as if:\n\n(a) it were both a professional service and a medical service; and\n\n(b) there were an item in the general medical services table that:\n\n(i) related to the service; and\n\n(ii) specified for the service a fee in relation to each State, being the fee specified in the Schedule in relation to the service.","sortOrder":4},{"sectionNumber":"7. Application of items 38495, 38514 and","sectionType":"part","heading":"7. Application of items 38495, 38514 and 38522","content":"# 7. Application of items 38495, 38514 and 38522\n\nMedicare benefit is not payable if the service described in item 38495, 38514 or 38522 is provided at the same time as, or in connection with, the provision of a pain pump for post‑surgical pain management.","sortOrder":5},{"sectionNumber":"8. Meaning of symbol (H)","sectionType":"part","heading":"8. Meaning of symbol (H)","content":"# 8. Meaning of symbol (H)\n\nAn item in this Schedule including the symbol (H) applies only to a service performed or provided in a hospital.","sortOrder":6},{"sectionNumber":"9. Indexation","sectionType":"part","heading":"9. Indexation","content":"# 9. Indexation\n\n (1) At the start of 1 July 2025 (the indexation time), each amount covered by subsection (2) is replaced by the amount worked out using the following formula:\n ![1.024 multiplied by the amount immediately before the indexation time](image.002.png)\n Note: The indexed fees could in 2025 be viewed on the Department of Health and Aged Care’s MBS Online website (https://www.mbsonline.gov.au).\n (2) The amounts covered by this subsection are the fee for each item in Schedule 1 of this Determination.\n (3) An amount worked out under subsection (1) is to be rounded up or down to the nearest 5 cents (rounding down if the amount is an exact multiple of 2.5 cents).","sortOrder":7},{"sectionNumber":"Schedule 1","sectionType":"part","heading":"relevant services","content":"# Schedule 1 – relevant services\n\n```html\n

Group A33 – Transcatheter Aortic Valve Implantation Case Conference

Item

Service

Fee ($)

6080

Coordination of a TAVI Case Conference by a TAVI Practitioner where the TAVI Case Conference has a duration of 10 minutes or more.

(Not payable more than once per patient in a five year period.)

53.80

6081

Attendance at a TAVI Case Conference by a specialist or consultant physician who does not also perform the service described in item 6080 for the same case conference where the TAVI Case Conference has a duration of 10 minutes or more.

(Not payable more than twice per patient in a five year period.)

40.15

Group T8 – Surgical Operations

Subgroup 6 – Cardio‑Thoracic

Item

Service

Fee ($)

38495

TAVI, for the treatment of symptomatic severe aortic stenosis, performed via transfemoral delivery, unless transfemoral delivery is contraindicated or not feasible, if:

(a) the TAVI Patient is at high risk for surgery; and

(b) the service:

(i) is performed by a TAVI Practitioner in a TAVI Hospital; and

(ii) includes all intraoperative diagnostic imaging that the TAVI Practitioner performs upon the TAVI Patient; and

(iii) includes valvuloplasty, if required;

not being a service which has been rendered within 5 years of a service to which this item or item 38514 or 38522 applies (H) (Anaes.) (Assist.)

1,514.10

38514

TAVI, for the treatment of symptomatic severe aortic stenosis, performed via transfemoral delivery, unless transfemoral delivery is contraindicated or not feasible, if:

(a) the TAVI Patient is at intermediate risk for surgery; and

(b) the service:

(i) is performed by a TAVI Practitioner in a TAVI Hospital; and

(ii) includes all intraoperative diagnostic imaging that the TAVI Practitioner performs upon the TAVI Patient; and

(iii) includes valvuloplasty, if required; and

(iv) is performed in a facility where cardiothoracic surgery is available and a thoracotomy can be performed immediately and without transfer; and

(v) if performed by an interventional cardiologist, a cardiothoracic surgeon is in attendance during the service;

not being a service which has been rendered within 5 years of a service to which this item or item 38495 or 38522 applies

(H) (Anaes.) (Assist.)

1,514.10

38522

TAVI, for the treatment of symptomatic severe native calcific aortic stenosis, performed via transfemoral delivery, unless transfemoral delivery is contraindicated or not feasible, if:

(a) the TAVI Patient is at low risk for surgery; and

(b) the service:

(i) is performed by a TAVI Practitioner in a TAVI Hospital; and

(ii) includes all intraoperative diagnostic imaging that the TAVI Practitioner performs upon the TAVI Patient; and

(iii) includes valvuloplasty, if required; and

(iv) is performed in a facility where cardiothoracic surgery is available and a thoracotomy can be performed immediately and without transfer; and

(v) if performed by an interventional cardiologist, a cardiothoracic surgeon is in attendance during the service;

not being a service which has been rendered within 5 years of a service to which this item or item 38495 or 38514 applies

(H) (Anaes.) (Assist.)

1,514.10

38523

Percutaneous transcatheter delivery of dual‑filter cerebral embolic protection system during a TAVI procedure, for the reduction of postoperative embolic ischaemic strokes, if:

(a) the service is performed upon a TAVI Patient in a TAVI Hospital; and

(b) where the service is performed by the practitioner performing the TAVI procedure, the service includes all intraoperative diagnostic imaging that the TAVI Practitioner performs upon the TAVI Patient

(H) (Anaes.) (Assist.)

275.20

\n```","sortOrder":8}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"Unauthenticated. Configure AI_GATEWAY_API_KEY or use a provider module. Learn more: https://ai-sdk.dev/unauthenticated-ai-gateway","source":"analysis-cron"},"flash_summary":{"complexity_score":6,"scope_assessment":{"changed":false,"description":"This Determination specifies and confines Medicare treatment and fees to the TAVI services and related case‑conference items listed in the Schedule and subject to the eligibility, venue, accreditation and documentation conditions in the Determination (see s6 and Schedule 1). It does not expand coverage beyond those expressly defined services."},"complexity_factors":["Technical medical eligibility criteria tied to patient surgical risk (high/intermediate/low) and procedural details in Schedule items 38495, 38514, 38522.","Multiple defined roles and accreditation requirements (TAVI Practitioner, TAVI Hospital, TAVI Patient) creating conditional entitlement (s5; Schedule).","Detailed case‑conference duties and documentation obligations (Attendance and Coordination definitions in s5) that create administrative compliance burden.","Payment frequency limits and caps (eg not payable more than once or twice per patient in specified periods) in Schedule items 6080 and 6081 and surgical items.","Operational conditions for procedural payment (availability of cardiothoracic surgery on site, surgeon attendance if cardiologist performs procedure, inclusion of intraoperative imaging and valvuloplasty) in Schedule.","Exclusion rule preventing Medicare benefit where TAVI is provided with a post‑surgical pain pump (s7).","Hospital‑only restriction via symbol (H) limiting setting where some items apply (s8; Schedule).","Indexation mechanics applying a 1.024 multiplier at 1 July 2025 with rounding rules (s9) introducing future fee adjustment complexity.","Cross‑references to the Health Insurance Act 1973 and the National Health Act 1953 and their regulations, requiring interpretation against those instruments (s3; s6)."],"plain_english_summary":"This Determination creates specific Medicare items and fees for Transcatheter Aortic Valve Implantation (TAVI) procedures and for coordinating/attending multidisciplinary TAVI case conferences. It also sets where services must be provided, record‑keeping and accreditation requirements, payment limits and a 2025 indexation. \n\nIt affects accredited TAVI Practitioners (cardiothoracic surgeons and interventional cardiologists), specialist attendees, TAVI Hospitals and patients assessed as suitable; it matters because it fixes when Medicare benefits are payable, what documentation is required, and which concurrent services (eg pain pumps) exclude payment."},"kimi_summary":{"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"The legislation remains tightly focused on its original purpose: establishing Medicare coverage for TAVI procedures and associated case conferences. While it has been amended to expand from high-risk patients only (original item 38495) to include intermediate-risk (38514) and low-risk patients (38522), and to add cerebral protection (38523), these changes represent natural expansion within the same clinical domain rather than scope creep into unrelated areas."},"complexity_factors":["9 defined terms in section 5, including nested definitions (e.g., 'TAVI Case Conference' contains 4 sub-clauses with multiple conditions)","3 separate procedure items (38495, 38514, 38522) with nearly identical structure but subtly different eligibility criteria (high vs intermediate vs low risk)","Cross-references to external legislation: Health Insurance Act 1973, National Health Act 1953, and Private Health Insurance Act 2007","Conditional logic with multiple nested requirements: each procedure item has 5+ conditions including facility requirements, practitioner attendance rules, and imaging inclusions","Temporal restrictions: 5-year exclusion period for repeat procedures, and frequency caps on case conference items (once per 5 years for coordination, twice for attendance)","Indexation formula in section 9 with mathematical calculation and rounding rules","Symbol notation system (H) requiring cross-reference to interpretation rules"],"plain_english_summary":"This law creates Medicare coverage for Transcatheter Aortic Valve Implantation (TAVI), enabling accredited cardiologists, surgeons, and approved hospitals to be paid for the procedure and related team planning, with an add‑on payment available for a brain‑protection device. It bars repeat claims in certain situations and requires surgical backup and imaging.\n\nIt affects patients with severe aortic stenosis (across surgical risk levels), the clinicians who perform and plan TAVI, and hospitals, ensuring access while enforcing safety and quality."}},"importantCases":[],"_links":{"self":"/api/acts/health-insurance-section-3c-general-medical-services-transcatheter-aortic-valve-implantation-determi","history":"/api/acts/health-insurance-section-3c-general-medical-services-transcatheter-aortic-valve-implantation-determi/history","analysis":"/api/acts/health-insurance-section-3c-general-medical-services-transcatheter-aortic-valve-implantation-determi/analysis","conflicts":"/api/acts/health-insurance-section-3c-general-medical-services-transcatheter-aortic-valve-implantation-determi/conflicts","importantCases":"/api/acts/health-insurance-section-3c-general-medical-services-transcatheter-aortic-valve-implantation-determi/important-cases","documents":"/api/acts/health-insurance-section-3c-general-medical-services-transcatheter-aortic-valve-implantation-determi/documents"}}