Medicare Benefits Schedule - Note TN.8.211

Claiming Guidance

• The service to which item 38285 applies may be claimed for the insertion of an implanted loop recorder (ILR) rendered to a patient as part of an episode of hospital treatment, including services provided in hospital outpatient settings.
• Private health insurers are required to pay benefits for products listed on the Prostheses List, if the product is rendered to a patient with the appropriate level of cover, as part of an episode of hospital treatment or hospital substitute treatment.
• When the ILR is inserted in the outpatient setting (the specialist or consultant physicians private rooms/clinic) the private insurer may opt to cover the cost of the device, but is not required to do so.

Related Items: 38285 38286

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Multiple Operation Rule

Insertion of implantable ECG loop recorder, by a specialist or consultant physician, for the diagnosis of a primary disorder, including initial programming and testing, if:

(a) the patient has recurrent unexplained syncope and does not have a structural heart defect associated with a high risk of sudden cardiac death; and

(b) a diagnosis has not been achieved through all other available cardiac investigations; and

(c) a neurogenic cause is not suspected

(Anaes.)

Fee: $169.80 Benefit: 75% = $127.35 85% = $144.35

(See para TN.8.61, TN.8.211 of explanatory notes to this Category)

Multiple Operation Rule

Removal of implantable ECG loop recorder

(Anaes.)

Fee: $152.95 Benefit: 75% = $114.75 85% = $130.05

(See para TN.8.211 of explanatory notes to this Category)