• 1 or more fractures occurring after minimal trauma; or

• for the monitoring of low bone mineral density proven by bone densitometry at least 12 months previously

• prolonged glucocorticoid therapy;
• conditions associated with excess glucocorticoid secretion;
• male hypogonadism; or
• female hypogonadism lasting more than 6 months before the age of 45

• primary hyperparathyroidism;
• chronic liver disease;
• chronic renal disease;
• proven malabsorptive disorders;
• rheumatoid arthritis; or
• conditions associated with thyroxine excess.

• the patient is 70 years of age or over; and
• either:
  1. the patient has not previously had bone densitometry; or
  2. the t score for the patient’s bone mineral density is -1.5 or more

• established low bone mineral density; or
• the confirmation of a presumptive diagnosis of low bone mineral density made on the basis of 1 or more fractures occurring after minimal trauma.

• the patient is 70 years of age or over; and
• the t score for the patient’s bone mineral density is less than -1.5 but more than -2.5

1. One [or more] of the following applies:
   • the patient has had an incomplete colonoscopy in the 3 months before the scan;
   • there is a high-grade colonic obstruction;
   • the patient is referred by a specialist or consultant physician who performs colonoscopies [in the practice of his or her speciality];
   and
2. The service is not a service to which item 56301, 56307, 56401, 56407, 56409, 56412, 56501, 56507, 56801,56807 or 57001 applies; and
3. The service has not been performed on the patient in the 36 months before the scan

1. the patient has stable symptoms consistent with coronary ischaemia, is at low to intermediate risk of coronary artery disease and would have been considered for coronary angiography; or
2. the patient requires exclusion of coronary artery anomaly or fistula; or
3. the patient will be undergoing non-coronary cardiac surgery

• Unexplained seizure(s)
• Unexplained chronic headache with suspected intracranial pathology

• Cervical radiculopathy

• Cervical spine trauma

• Inability to extend the knee suggesting the possibility of acute meniscal tear or;
• Clinical findings suggesting acute anterior cruciate ligament tear

• Unexplained seizure
• Unexplained headache where significant pathology is suspected
• Paranasal sinus pathology which has not responded to conservative therapy.

• Significant trauma
• Unexplained neck or back pain with associated neurological signs
• Unexplained back pain where significant pathology is suspected

• Suspected septic arthritis
• Suspected slipped capital femoral epiphysis
• Suspected perthes disease

2D Mammography Bilateral Breasts

Where there is a reason to suspect the presence of malignancy because of:

 
1. the past occurrence of breast malignancy in the patient or members of the patient’s family (blood relative); or
2. symptoms or indications of malignancy found on an examination of the patient by a medical practitioner

Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness. For previous history of malignancy in patient or family member please provide relevant history. It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

2D Mammography Breast

Where there is reason to suspect the presence of malignancy because of:

 
1. the past occurrence of breast malignancy in the patient or members of the patient’s family; or
2. symptoms or indications of malignancy found on an examination of the patient by a medical practitioner.

Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness. For previous history of malignancy in patient or family member please provide relevant history. It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

3D Tomosynthesis Bilateral Breasts

Where there is a reason to suspect the presence of malignancy because of:

 
1. the past occurrence of breast malignancy in the patient or members of the patient’s family (blood relative); or
2. symptoms or indications of malignancy found on an examination of the patient by a medical practitioner

Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness. For previous history of malignancy in patient or family member please provide relevant history. It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

3D Tomosynthesis Breast

Where there is reason to suspect the presence of malignancy because of:

 
1. the past occurrence of breast malignancy in the patient or members of the patient’s family; or
2. symptoms or indications of malignancy found on an examination of the patient by a medical practitioner.

Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness. For previous history of malignancy in patient or family member please provide relevant history. It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

 
1. hyperemesis gravidarum;
2. diabetes mellitus;
3. hypertension;
4. toxaemia of pregnancy;
5. liver or renal disease;
6. autoimmune disease;
7. cardiac disease;
8. alloimmunisation;
9. maternal infection;
10. inflammatory bowel disease;
11. bowel stoma;
12. abdominal wall scarring;
13. previous spinal or pelvic trauma or disease;
14. drug dependency;
15. thrombophilia;
16. significant maternal obesity;
17. advanced maternal age;
18. abdominal pain or mass;
19. uncertain dates;
20. high risk pregnancy;
21. previous post dates delivery;
22. previous caesarean section;
23. poor obstetric history;
24. suspicion of ectopic pregnancy;
25. risk of miscarriage;
26. diminished symptoms of pregnancy;
27. suspected or known cervical incompetence;
28. suspected or known uterine abnormality;
29. pregnancy after assisted reproduction;
30. risk of fetal abnormality

 
1. hyperemesis gravidarum;
2. diabetes mellitus;
3. hypertension;
4. toxaemia of pregnancy;
5. liver or renal disease;
6. autoimmune disease;
7. cardiac disease;
8. alloimmunisation;
9. maternal infection;
10. inflammatory bowel disease;
11. bowel stoma;
12. abdominal wall scarring;
13. previous spinal or pelvic trauma or disease;
14. drug dependency;
15. thrombophilia;
16. significant maternal obesity;
17. advanced maternal age;
18. abdominal pain or mass;
19. uncertain dates;
20. high risk pregnancy;
21. previous post dates delivery;
22. previous caesarean section;
23. poor obstetric history;
24. suspicion of ectopic pregnancy;
25. risk of miscarriage;
26. diminished symptoms of pregnancy;
27. suspected or known cervical incompetence;
28. suspected or known uterine abnormality;
29. pregnancy after assisted reproduction;
30. risk of fetal abnormality

 
1. hyperemesis gravidarum;
2. diabetes mellitus;
3. hypertension;
4. toxaemia of pregnancy;
5. liver or renal disease;
6. autoimmune disease;
7. cardiac disease;
8. alloimmunisation;
9. maternal infection;
10. inflammatory bowel disease;
11. bowel stoma;
12. abdominal wall scarring;
13. previous spinal or pelvic trauma or disease;
14. drug dependency;
15. thrombophilia;
16. significant maternal obesity;
17. advanced maternal age;
18. abdominal pain or mass;
19. uncertain dates;
20. high risk pregnancy;
21. previous post dates delivery;
22. previous caesarean section;
23. poor obstetric history;
24. suspicion of ectopic pregnancy;
25. risk of miscarriage;
26. diminished symptoms of pregnancy;
27. suspected or known cervical incompetence;
28. suspected or known uterine abnormality;
29. pregnancy after assisted reproduction;
30. risk of fetal abnormality

 
1. the patient is referred by a medical practitioner; and
2. the dating for the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks of gestation; and
3. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
4. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
5. the service is not performed in the same pregnancy as item 55709

Specialist Referral Only

 
1. the patient is referred by a medical practitioner who is a Member or a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has a qualification recognised by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists as being equivalent to a Diploma of Obstetrics or has obstetric privileges at a non-metropolitan hospital; and
2. the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks of gestation; and
3. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
4. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
5. further examination is clinically indicated in the same pregnancy to which item 55706 applies

 
1. the patient is referred by a medical practitioner; and
2. the dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
3. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
4. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
5. the service is not performed in the same pregnancy as item 55723; and
6. one or more of the following conditions are present:
    
   1. known or suspected fetal abnormality or fetal cardiac arrhythmia;
   2. fetal anatomy (late booking or incomplete mid-trimester scan);
   3. malpresentation;
   4. cervical assessment;
   5. clinical suspicion of amniotic fluid abnormality;
   6. clinical suspicion of placental or umbilical cord abnormality;
   7. previous complicated delivery;
   8. uterine scar assessment;
   9. uterine fibroid;
   10. previous fetal death in utero or neonatal death;
   11. antepartum haemorrhage;
   12. clinical suspicion of intrauterine growth retardation;
   13. clinical suspicion of macrosomia;
   14. reduced fetal movements;
   15. suspected fetal death;
   16. abnormal cardiotocography;
   17. prolonged pregnancy;
   18. premature labour;
   19. fetal infection;
   20. pregnancy after assisted reproduction;
   21. trauma;
   22. diabetes mellitus;
   23. hypertension;
   24. toxaemia of pregnancy;
   25. liver or renal disease;
   26. autoimmune disease;
   27. cardiac disease;
   28. alloimmunisation;
   29. maternal infection;
   30. inflammatory bowel disease;
   31. bowel stoma;
   32. abdominal wall scarring;
   33. previous spinal or pelvic trauma or disease;
   34. drug dependency;
   35. thrombophilia;
   36. significant maternal obesity;
   37. advanced maternal age;
   38. abdominal pain or mass

Specialist Referral Only

 
1. the patient is referred by a medical practitioner who is a Member or a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has qualifications recognised by the Royal Australian and New Zealand College of Obstericians and Gynaecologists as being equivalent to a Diploma of obstetrics or has obstetric privileges at a non-metropolitan hospital; and
2. the dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
3. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
4. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
5. further examination is clinically indicated in the same pregnancy to which item 55718 applies

 
1. the patient is referred by a medical practitioner; and
2. ultrasound of the same pregnancy confirms a multiple pregnancy; and
3. the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks gestation; and
4. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
5. the referring practitioner is not a member of a group of practitioners to which the providing practitioner is a member; and
6. the service is not performed in conjunction with item 55706 or 55712 during the same pregnancy

Specialist Referral Only

 
1. the patient is referred by a medical practitioner who is a Member or Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has a qualification recognised by the Royal Australian and New Zealand College of Obstericians and Gynaecologists as equivalent to a Diploma of obstetrics or has obstetric privileges at a non-metropolitan hospital; and
2. ultrasound of the same pregnancy confirms a multiple pregnancy; and
3. the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks gestation; and
4. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
5. the referring practitioner is not a member of a group of practitioners to which the providing practitioner is a member; and
6. further examination is clinically indicated in the same pregnancy to which item 55759 has been performed; and
7. not performed in conjunction with item 55706 or 55712 during the same pregnancy

 
1. dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
2. the ultrasound confirms a multiple pregnancy; and
3. the patient is referred by a medical practitioner; and
4. the service is not performed in the same pregnancy as item 55770; and
5. the service is not associated with a service to which an item in Subgroups 2 or 3 of this group applies; and
6. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
7. the service is not performed in conjunction with item 55718 or 55721 during the same pregnancy

Specialist Referral Only

 
1. dating of the pregnancy as confirmed by ultrasound is after 22 weeks of gestation; and
2. the patient is referred by a medical practitioner who is a Member or Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has a qualification recognised by the Royal Australian and New Zealand College of Obstericians and Gynaecologists as equivalent to a Diploma of obstetrics or has obstetric privileges at a non-metropolitan hospital; and
3. further examination is clinically indicated in the same pregnancy to which item 55768 or 55770 has been performed; and
4. the pregnancy as confirmed by ultrasound is a multiple pregnancy; and
5. the service is not associated with a service to which an item in Subgroups 2 or 3 of this group applies; and
6. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
7. the service is not performed in conjunction with item 55718 or 55721 during the same pregnancy

 
• evaluation of injury to tendon, muscle or muscle/tendon junction; or
• rotator cuff tear/calcification/tendinosis (biceps, subscapular, suspraspinatus, infraspinatus); or
• biceps subluxation; or
• capsulitis and bursitis; or
• evaluation of mass including ganglion; or
• occult fracture; or
• acromioclavicular joint pathology
 


Benefits are not payable when referred for non-specific pain alone

 
• abnormality of tendons or bursae about the knee; or
• meniscal cyst, popliteal fossa cyst, mass or pseudomass; or
• nerve entrapment, nerve or nerve sheath tumour; or
• injury of collateral ligaments
 


Benefits are not payable when referred for non-specific pain alone and including meniscal or cruciate ligament tears and assessment of chondral surfaces