Transcription of Part A - Prostheses List February 2011
1 Part A - Prostheses ListFebruary 2011 CARDIO-THORACICB illing Code Product NameDescriptionSizeNotationsMinimum BenefitMaximum BenefitGroup 1- Cardiothoracic Mechanical ValvesGroup 1c - Bi-Leaflet, rotatableMedtronic Australasia Pty LtdMC292 Advantage Heart Valve - Aortic Model A7760A7760 - Pyrolytic carbon, PETD iameter 19-31 mm$6, Supra Aortic Heart ValveMechanical Heart Valve Pyrolite Carbon leaflets Pyrolite carbon ringDiameter (mm): 19 - 25$6, MitralMechanical Heart Valve23mm-33mm$6, Pivot Heart Valve (Model 500FA)Open Pivot Heart Valve (Model 500DM)Pyrolythic Carbon, Double Velour Polyester, Titanium16-33mm$6, Pivot Heart Valve (Model 501DA)Open Pivot Heart Valve (Model 501DM)Pyrolythic Carbon, Double Velour Polyester, Titanium16-33mm$6, HealthcareRH001 Aortic On-X Prosthetic Heart Valve Models ONXA-19; ONXA-21; ONXA-23; ONXA-25; ONXA-27/29; ONXM-23; ONXM-25; ONXM-27/29; ONXM31/33.
2 ONXMC25/3327-29mm, 19mm, 21mm, 23mm, 25mm, 25-33mm, 27-29mm, 31-33mm, 23mm, 25mm$6, GroupSA129 OptiformMechanical Valve19mm to 33mm$6, Jude Medical Australia Pty LtdSJ037St Jude Medical Aortic Expanded Cuff Heart Valve; St Jude Medical Aortic Hemodynamic Plus Cuff Heart Valve; St Jude Medical Mitral Hemodynamic Plus Cuff Heart Valve; St Jude Medical Mechanical Heart Valve Masters SeriesAortic Expanded Cuff, Aortic Hemodynamic Plus Cuff, Mitral Hemodynamic Cuff, Aortic & Mitral Rotatable CuffAortic Expanded 19 -31mm, Aortic Hemodynamic 17 - 27mm, Mitral Hemodynamic 17 -27mm, Rotatable 17 - 33mm$6, 1 of 920 Prostheses List by Category, Groups and SponsorCARDIO-THORACICB illing Code Product NameDescriptionSizeNotationsMinimum BenefitMaximum BenefitSJ039 Regent Prosthestic Heart ValvesStandard Cuff - Model 17 AGFN-751 - 23 AGFN-751, Flex Cuff - Mode 17 AGFN-756 - 23 AGFN-756 Standard cuff - 17-23mm.
3 Flex cuff - 17-23mm$6, Prosthestic Heart ValvesStandard Cuff - Model 25 AGFN-751 - 29 AGFN-751, Flex Cuff - Mode 25 AGFN-756 - 29 AGFN-756 Standard cuff - 25-29mm, Flex cuff - 25-29mm$6, 1e - Tilting Disc, rotatableMedtronic Australasia Pty LtdMC013 Medtronic Hall Heart Valve Aortic Model A7700, Medtronic Hall Heart Valve Mitral Model M7700, Hall Easy Fit Aortic Heart Valve Model A7700, Hall Easy Fit Mitral Heart Valve Model M7700A7700/M7700 Titanium. Pyrolite. Dacron, A7700EZ/M7700EZ Titanium. Pyrolite. PETA7700 - Diameter 20-31mm, M7700 - Diameter 23-33mm, A7700EZ - Diameter 19-29mm, M7700EZ - Diameter 23-31mm$5, $5, 1: Single Chamber ICD'sGeneration 3 Guidant Australia Pty LtdGU148 Vitality 2 EL VR - Model T177 Single Chamber ICD35cc; 90g$40, 2 VR - Model T 175 Single Chamber ICD30cc; 82g$40, GroupSA139 OVATIO VR 6250 Titanium, single chamber, sterile, VR 6250, 34J29cc$40, GroupSA149 PARADYM VR 8250 Single Chamber implantable cardioverter defibrillator with rate responseDimensions: x x 11mm; Weight: 90 grams.
4 Volume: $42, Jude Medical Australia Pty LtdSJ066 Atlas + VR - C Model V-193C ICDS ingle chamber implantable cardio-verter defibrillator38cc, 77g$42, II VR-168 Single chamber cardioverter defibrillator38cc, 77g$42, 2 of 920 Prostheses List by Category, Groups and SponsorCARDIO-THORACICB illing Code Product NameDescriptionSizeNotationsMinimum BenefitMaximum BenefitSJ121 Current VR 1107-36 Single Chamber Cardioverter Defibrillator38cc 76g$42, , c, dMedtronic Australasia Pty LtdMC722 VirtuosoVR Model Implantable Cardioverter Defibrillator, Single Chamber37cc, 68g$42, , dBiotronik Australia Pty LtdBT090 Lumax 340 VR-TICD-VR 34 J with bidirectional Home Monitoring.
5 Single chamberOne size only$45, $42, 340 VR-T XLICD-VR with 40 J output, bidirectional Home Monitoring and High LongevityOne Size Only$45, $42, Scientific Australia Pty LtdBS136 TELIGEN 100 HE VR DF-1/IS-1 Single chamber ICD, High Energy with , $42, Australasia Pty LtdMC939 Virtuoso IIVR Model - Implantable Cardioverter Defibrillator, Single Chamber37cc, 68g$42, Jude Medical Australia Pty LtdSJ124 Current RF VR 1207-36 Single Chamber Cardioverter Defibrillator with RF Telemetry79g, 41cc$42, VR CD1217-36 Single Chamber Cardioverter Defibrillator with RF Telemetry and ST Segment Monitoring79g, 41cc$44, $42, , d, eBoston Scientific Australia Pty LtdBS132 Teligen 100 HE VR 4-SITES ingle chamber ICD, high energy with , $43, Australia Pty LtdBT087 Lumax 300 VR-TICD-VR with bidirectional Home Monitoring.
6 Single chamberOne Size Only$43, $40, 3 of 920 Prostheses List by Category, Groups and SponsorCARDIO-THORACICB illing Code Product NameDescriptionSizeNotationsMinimum BenefitMaximum BenefitSt Jude Medical Australia Pty LtdSJ216 AnalyST VR CD1217-30 Single chamber cardioverter defibrillator with RF telemetry and ST segment monitoring73g, 37cc$42, $40, 4a, dBiotronik Australia Pty LtdBT100 LUMAX 540 VR-THigh Energy, Single-Chamber ICD (Implantable Cardiac Defibrillator) with Advanced Patient Management Via unique Home Monitoring Technology incorporatin Automatic Threshold Monitoring and Extended : 66*55*13 mm Volume/Weight.
7 $45, $43, Australasia Pty LtdMC813 Secura VRFully Automatic, Wireless Implantable cardioverter defibrillator with high energy capability and therapies for ventricular tachyarrhythmia37cc$43, XT VR D354 VRGS ingle chamber implantable cardioverter defribillator with SmartShock Technology, OptiVol Fluid Status Monitoring and Complete Capture Management Specifications (DF-1)Volume 37cc, Mass 68g$43, Jude Medical Australia Pty LtdSJ147 Current Accel VR RF CD1215-36 Single Chamber Cardioverter Defibrillator with RF Telemetry79g, 38cc$44, $43, Accel VR CD1219-36 Single Chamber Cardioverter Defibrillator with RF Telemetry and ST Segment Monitoring79g, 41cc$44, $43, VR CD1233-40 Single chamber cardioverter defibrillator with 40J delievered energy35cc, 75g$43, ST VR CD1235-40 Single chamber cardioverter defibrillator with 40J delivered energy and ST segment monitoring35cc, 75g$43, 4 of 920 Prostheses List by Category.
8 Groups and SponsorCARDIO-THORACICB illing Code Product NameDescriptionSizeNotationsMinimum BenefitMaximum Benefita, d, eSt Jude Medical Australia Pty LtdSJ232 Current Accel VR CD1215-36 QSingle Chamber Cardioverter Defibrillator with RF Telemetry and SJ4 connector80g, 42cc$44, Accel VR CD1219-36 QSingle Chamber Cardioverter Defibrillator with RF Telemetry and ST Segment Monitoring and SJ4 , 41cc$44, VR CD1233-40 QSingle chamber cardioverter defribillator with 40J delivered energy with SJ4 connector35cc, 75g$44, ST VR 1235-40 QSingle chamber cardioverter defibrillator with 40J delivered energy and ST segment monitoring and SJ4 connector35cc, 75g$44, Jude Medical Australia Pty LtdSJ212 AnalyST Accel VR CD1219-30 Single chamber cardioverter defibrillator with RF telemetry and ST segment monitoring73g, 37cc$44, $41, Accel VR RF CD1215-30 Single chamber cardioverter defibrillator with RF telemetry73g, 37cc$44, $41, 10: Pacemaker/ICD ExtendersMedtronic Australasia Pty LtdMC831 Medtronic Lead Extender Kit Model.
9 6984M, 6981M, 6985M,6986mSilicone37 - 50cm$ 5 of 920 Prostheses List by Category, Groups and SponsorCARDIO-THORACICB illing Code Product NameDescriptionSizeNotationsMinimum BenefitMaximum BenefitGroup 11: Pacemaker/Lead AccessoriesMedtronic Australasia Pty LtdMC036 Medtronic Lead End Cap Kit Model: 5867-3M; Medtronic DF-1 Port Pin Plug Kit: Model 6719, Medtronic IS-1 Port Pin Plug Kit: Model 6725; Medtronic Upsizing Sleeve: Model 5866-45, Model 5866-46 Pin Plug Kits to Seal Unused Pacemaker or Defibrillator Port; Sizing Sleeve - Silicone or PolyurethaneOne Size Per Model$ 12: Coronary StentsSub-Group 1: General Purpose Drug eluting stentsAbbott Australasia Pty LtdAY023 Xience Everolimus Eluting Stent SystemEverolimus Eluting Stent to widths, 8mm to 28mm lengths$3, Xience PRIME LL Everolimus Eluting Coronary Stent; Xience PRIME Everolimus Eluting Coronary Stent; Xience PRIME SV Everolimus Eluting Coronary StentCoronary Artery Stent, Drug ElutingXIENCE PRIME LL ; ; ; ; x 33MM; XIENCE PRIME LL ; ; ; ; x 38MM; XIENCE PRIME SV x 08; 12; 15; 18; 23; 28MM.
10 XIENCE PRIME x 08; 12; 15; 18; 23; 28MM; XIENCE PRIME x 08; 12; 15; 18; 23; 28MM; XIENCE PRIME x 08; 12; 15; 18; 23; 28MM; XIENCE PRIME x 08; 12; 15; 18; 23; 28MM; XIENCE PRIME x 08; 12; 15; 18; 23; 28MM$3, Scientific Australia Pty LtdBS099 Taxus Liberte Paclitaxel-Eluting Coronary Stent System316L Stainless Steel Stent with Translute Polymer and & $3, 6 of 920 Prostheses List by Category, Groups and SponsorCARDIO-THORACICB illing Code Product NameDescriptionSizeNotationsMinimum BenefitMaximum BenefitBS125 Promus Everolimus Coronary Stent SystemCobalt chromium alloy stent coated with a blended polymer mixed with to diameter, 8mm to 28mm length$3.
