Medicare Benefits Schedule - Note TN.1.29

For the purpose of administering MBS item 13761 and item 13762, treatment cycle refers to a 12-week time period.

A cycle of treatment funded under item 13762 can be preceded by a cycle funded by either item 13761 or by item 13762, provided at least a partial organ response occurs. A response, for the purposes of administering MBS item 13762, is defined as attaining a complete or partial response in at least one organ according to National Institutes of Health (NIH) criteria. A response only needs to be demonstrated after the first 12 weeks of treatment.

Patient Requirements

For the purpose of administering MBS item 13761 and item 13762, steroid-refractory or steroid-dependent disease is defined as one of the following:

1. A lack of response or disease progression after a minimum of prednisone 1 mg/kg/day or equivalent for at least 1 week, OR
2. Disease persistence without improvement despite continued treatment with prednisone at > 0.5 mg/kg/day or 1 mg/kg every day or equivalent other day for at least 4 weeks, OR
3. Increase to prednisolone dose to > 0.25 mg/kg/day or equivalent after 2 unsuccessful attempts to taper the dose.

Related Items: 13761 13762

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Extracorporeal photopheresis for the treatment of chronic graft-versus-host disease, if:

(a)     the person is:

(i)        has received allogeneic haematopoietic stem cell transplantation; and

(ii)        has been diagnosed with chronic graft versus host disease following the transplantation; and

(iii)      steroid treatment is clinically unsuitable as the disease is steroid refractory or the person is steroid-dependent or steroid-intolerant; and

(b)    the person has not previously received an extracorporeal photopheresis treatment cycle; and

(c)     the service is delivered using an integrated, closed extracorporeal photopheresis system; and

(d)    the service is provided in combination with the use of methoxalen that is listed on the Pharmaceutical Benefits Scheme; and

(e)     the service is provided by, or on behalf of, a specialist or consultant physician who:

(i)   is practising in the speciality of haematology or oncology; and

(ii)  has experience with allogeneic bone marrow transplantation.

Applicable once per treatment cycle

Fee: $1,938.90 Benefit: 75% = $1,454.20 85% = $1,845.70

(See para TN.1.29 of explanatory notes to this Category)

Extracorporeal photopheresis for the treatment of chronic graft-versus-host disease, if:

(a)     the person is:

(i)     has received allogeneic haematopoietic stem cell transplantation; and

(ii)       has been diagnosed with chronic graft versus host disease following the transplantation; and

(iii)     steroid treatment is clinically unsuitable as the disease is steroid refractory or the person is steroid-dependent or steroid-intolerant; and

(b)    the person has previously received an extracorporeal photopheresis treatment cycle and had a partial or complete response in at least one organ in response to treatment; and

(c)     the person requires further extracorporeal photopheresis; and

(d)    the service is delivered using an integrated, closed extracorporeal photopheresis system; and

(e)     the service is provided in combination with the use of methoxalen that is listed on the Pharmaceutical Benefits Scheme; and

(f)      the service is provided by, or on behalf of, a specialist or consultant physician who:

(i)   is practising in the speciality of haematology or oncology; and

(ii)  has experience with allogeneic bone marrow transplantation.

Applicable once per treatment cycle

Fee: $1,938.90 Benefit: 75% = $1,454.20 85% = $1,845.70

(See para TN.1.29 of explanatory notes to this Category)