Medicare Benefits Schedule - Note CN.3.1

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Category 7 - CLEFT LIP AND CLEFT PALATE SERVICES

CN.3.1

Patient Eligibility

To be eligible to claim benefits for Schedule services performed by eligible medical and dental practitioners, a patient must satisfy the following criteria:

a. The patient must be an Australian resident or any other person or class of persons whom the Minister declares to be eligible. All eligible persons will be issued with a Medicare card on application as evidence of their eligibility.

b. Under the provisions of Section 3BA of the Health Insurance Act 1973, a patient must be a prescribed dental patient. To be a prescribed dental patient, a person must meet one of the following categories:

 Certified with a cleft palate and cleft lip condition before the age of 22 years

a) an approved medical practitioner or dental practitioner has issued a certificate that states that the person is suffering from a cleft lip or a cleft palate condition; and

b) the person has not attained the age of 22 years.

Certified with a cleft palate and cleft lip condition and is aged between 22 and 27 years

 a) before the person attained the age of 22 years, an approved medical practitioner or dental practitioner issued a certificate that states that the person is suffering from a cleft lip or a cleft palate condition; and

b) the person has attained the age of 22 years, but has not attained the age of 28 years; and

c) the person’s treatment for the condition started before the person attained the age of 22 years.

 Certified with a cleft palate and cleft lip condition and is aged 28 years and over

 A person is also a prescribed dental patient, in relation to a particular course of treatment, if:

a) before the person attained the age of 22 years, an approved medical practitioner or dental practitioner issued a certificate that states that the person is suffering from a cleft lip or a cleft palate condition; and

 b) the person has attained the age of 28 years; and

 c) before the person attained the age of 28 years, he or she received treatment for the condition; and

 d) the Minister declares in writing that he or she is satisfied that:

 i.  because of exceptional circumstances, the person requires repair of previous reconstructive surgery in connection with the condition; and

ii. the person therefore needs to undergo that course of treatment.

 Certified with a condition approved by the Minister

a) an approved medical practitioner or dental practitioner has issued a certificate that states that the person is suffering from a condition determined by the Minister to be a condition to which this definition applies (these additional conditions are outlined below); and

b) the person has not attained the age of 22 years.

A Ministerial Determination, the Health Insurance (Prescribed Dental Patient) Determination 2015, is in place for these 'other' conditions, enabling the payment of Medicare benefits for the conditions listed below:

1. Oral and/or facial clefting
Limited to Cleft lip, alveolus and/or palate
  Tessier facial cleft
2. Congenital or hereditary craniofacial malformation, deformation or disruption
Limited to Achondroplasia
  Branchial arch disorders including: Hemifacial/craniofacial microsomia, Goldenhar syndrome, DiGeorge syndrome, Velocardiofacial syndrome
  CHARGE syndrome
  Congenital hemifacial hyperplasia
  Congenital lymphatic and/or vascular malformations of the head & neck, cystic hygroma, Sturge-Weber syndrome, excluding haemangiomas, birth marks and naevi.
  Craniofacial Neurofibromatosis Type 1
  Craniometaphyseal dysplasia
  Ectodermal dysplasia
  Hemifacial atrophy (Parry Romberg syndrome)
  Mandibulofacial dysostosis (Treacher Collins syndrome)
  Maxillonasal dysplasia (Binder syndrome)
  Oral-facial digital syndrome Type 1
  Pierre Robin sequence
  Rubinstein-Taybi syndrome
  Sphrintzen-Goldberg syndrome
  Solitary median maxillary central incisor syndrome
  Stickler syndrome
  Syndromic craniosynostoses including:
Apert, Crouzon, Pfeiffer, Saethre Chotzen, and Muenke syndromes
  Trichorhinophalangeal syndrome Type 1
3. Hereditary conditions presenting with the absence of 6 (six) or more permanent teeth, excluding 3rd molars
4. Hereditary conditions where the presence of supernumerary teeth is a major feature
5. Hereditary conditions affecting the formation of enamel and/or dentine of all teeth
Limited to Amelogenesis imperfecta
  Dentinogenesis imperfecta
  Regional odontodysplasia

 


Legend

  • Assist - Addition/Deletion of (Assist.)
  • Amend - Amended Description
  • Anaes - Anaesthetic Values Amended
  • Emsn - EMSN Change
  • Fee - Fee Amended
  • Renum - Item Number Change (renumbered)
  • New - New Item
  • NewMin - New Item (previous Ministerial Determination)
  • Qfe - QFE Change