Medicare Benefits Schedule - Note PR.7.1

A patient is eligible for a service described in any of items 73384 to 73387 only if:

(a)  the patient or the patient’s reproductive partner:

1. has an identified gene variant which places the patient at risk of having a pregnancy affected by a Mendelian or mitochondrial disorder; or
2. is at risk of an autosomal dominant disorder which places the patient at risk of having a child who develops the autosomal dominant disorder; or
3. has a chromosome re‑arrangement or copy number variant which places the patient at risk of having a pregnancy affected by a chromosome disorder; and

(b)  there is no curative treatment for the disorder and there is severe limitation of quality of life despite contemporary management of the disorder; and

(c)  the patient has previously had a consultation, with a specialist or consultant physician practising as a clinical geneticist, that included a discussion about the disorder.

Related Items: 13207 73384 73385 73386 73387

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Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A of the pathology services table (see PR.7.1), of samples from the patient and (if relevant) the patient’s reproductive partner, for the purpose of providing an assay for pre‑implantation genetic testing, requested by a specialist or consultant physician

Applicable not more than once per patient episode per disorder (of a kind described in clause 2.7.3A (PR.7.1)) per reproductive relationship

Fee: $1,736.00 Benefit: 75% = $1,302.00 85% = $1,637.30

(See para PR.7.1, TN.1.4 of explanatory notes to this Category)

Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A of the Pathology Services Table (see PR.7.1), of embryonic tissue from a sample from one embryo, if:

(a) the analysis is:

(i) requested by a specialist or consultant physician; and

(ii) for the purpose of providing a pre‑implantation genetic test; and

(iii) performed on an embryo that was produced in a single assisted reproductive treatment cycle; and

(b) the service is not a service to which item 73386 or 73387 applies for the same assisted reproductive treatment cycle

Applicable not more than once per embryo

Fee: $635.00 Benefit: 75% = $476.25 85% = $539.75

(See para PR.7.1, TN.1.4 of explanatory notes to this Category)

Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A of the Pathology Services Table (see PR.7.1), of embryonic tissue from samples from 2 embryos, if:

(a) the analysis is:

(i) requested by a specialist or consultant physician; and

(ii) for the purpose of providing a pre‑implantation genetic test; and

(iii) performed on embryos that were produced in a single assisted reproductive treatment cycle; and

(b) the service is not a service to which item 73385 or 73387 applies for the same assisted reproductive treatment cycle

Applicable not more than once per assisted reproductive treatment cycle for the 2 embryos tested

Fee: $1,270.00 Benefit: 75% = $952.50 85% = $1,171.30

(See para PR.7.1, TN.1.4 of explanatory notes to this Category)

Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A of the Pathology Services Table (see PR.7.1), of embryonic tissue from samples from 3 or more embryos, if:

(a) the analysis is:

(i) requested by a specialist or consultant physician; and

(ii) for the purpose of providing a pre‑implantation genetic test; and

(iii) performed on embryos that were produced in a single assisted reproductive treatment cycle; and

(b) the service is not a service to which item 73385 or 73386 applies for the same assisted reproductive treatment cycle

Applicable not more than once per assisted reproductive treatment cycle for the 3 or more embryos tested

Fee: $1,905.00 Benefit: 75% = $1,428.75 85% = $1,806.30

(See para PR.7.1, TN.1.4 of explanatory notes to this Category)

Biopsy of an embryo, from a patient who is eligible for a service described in item 73384 under clause 2.7.3A of the pathology services table (see PR.7.1), for the purpose of providing a sample for pre-implantation genetic testing—applicable to one or more tests performed in one assisted reproductive treatment cycle

Fee: $125.90 Benefit: 75% = $94.45 85% = $107.05

(See para PR.7.1 of explanatory notes to this Category)