Medicare Benefits Schedule - Note CN.3.1

To be eligible to claim benefits for cleft and dental services performed by eligible medical and registered 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; and

b.       The patient must be diagnosed with an eligible cleft or craniofacial condition specified in the Health Insurance (Section 3C General Medical Services - Cleft and Craniofacial Services) Determination 2024.

The Health Insurance (Section 3C General Medical Services - Cleft and Craniofacial Services) Determination 2024 specifies the eligible cleft or craniofacial 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, Auriculo-condylar 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
	Congenital lymphatic and vascular malformations and segmental haemangiomas involving the jaws and associated soft tissues including cystic hygroma and Sturge-Weber syndrome
	Ectodermal dysplasia
	Hemifacial atrophy (Parry Romberg syndrome)
	Mandibulofacial dysostosis (Treacher Collins syndrome)
	Maxillonasal dysplasia (Binder syndrome)
	Oral-facial digital syndrome Type 1
	Osteogenesis imperfercta
	Pierre Robin sequence
	Rubinstein-Taybi syndrome
	Shprintzen-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
Limited to	Cleidocranial dysplasia
	Gardner's syndrome
5. Development or hereditary conditions affecting the formation of enamel and/or dentine of all teeth
Limited to	Amelogenesis imperfecta
	Dentinogenesis imperfecta
	Regional odontodysplasia

 

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