1.1 The LSA will pay for necessary and reasonable medical treatment including:
1.1.1 medical and surgical treatment;
1.1.3 diagnostic tests such as imaging services;
1.1.4 inpatient or outpatient treatment provided by a hospital;
1.1.5 medical treatment, reports, case conferences or other contact with other professionals treating the participant; and
1.1.6 other specialised medical treatment such as assisted fertility treatment and treatment for chronic pain.
1.2 The LSA does not pay for:
1.2.1 fees associated with medico-legal reports or any medical reports not requested by the LSA;
1.2.2 additional expenses incurred while receiving inpatient or outpatient medical treatment such as food, magazines, phone line rental and phone calls;
1.2.3 a treatment or service not in accordance with the MBS explanations, definitions, rules and conditions for services provided by medical practitioners, unless otherwise specified by the LSA;
1.2.4 a treatment or service without a MBS code;
1.2.5 a treatment or service where there is no published evidence relating to its safety or effectiveness;
1.2.6 non-attendance fees where a participant failed to attend unless the MBS states otherwise or the reason for non-attendance is beyond the participant’s control;
1.2.7 a treatment or service for any other member of the participant’s family unless the family member is the recipient of assisted fertility treatment in accordance with Part 21 Rule 5.6 below, or when a family member is receiving counselling services in accordance with Part 6 Rule 2.2; and
1.2.8 a treatment or service that is of no clear benefit to a participant.
2.1 Information required by the LSA to assess a participant’s treatment, care and support needs in connection with medical treatment may include:
2.1.1 information relating to the medical treatment that has an item number in the MBS;
2.1.2 information about pre-existing or co-existing medical conditions;
2.1.3 information from a medical practitioner as to the likely cause of the presenting medical treatment, if the participant has pre- or co-existing medical conditions that may impact on their needs for or in connection with medical treatment or pharmaceuticals;
2.1.4 clinical assessments and reports;
2.1.5 justification for the proposed treatment, including the relationship to the motor accident; necessary and reasonable criteria; and
2.1.6 justification for the treatment process, including any associated medical treatment as part of an overall treatment plan.
2.2 The following procedures are to be followed when assessing treatment, care and support needs in connection with medical treatment:
2.2.1 the medical treatment must be prescribed by an appropriate specialist or medical practitioner registered with the AHPRA (or other appropriate professional body if the participant resides outside Australia); and
2.2.2 the treatment must be approved by the LSA prior to commencement in all circumstances, unless the treatment is urgent; and
2.2.3 the medical practitioner or specialist is to provide medical services using the AMA item numbers, where there is a corresponding MBS number.
3.1 The LSA considers necessary and reasonable treatment, care and support needs in connection with pharmaceuticals to include:
3.1.1 prescription pharmaceuticals;
3.1.2 over the counter medications;
3.1.3 prescribed vitamins and supplements, including health products such as fibre laxatives or probiotics;
3.1.4 topical skin creams such as sorbolene; and
3.1.5 consumable preparation solutions for a medical procedure.
3.2 Bandages, dressings and other wound care items, and consumable items for continence needs, may either be pharmaceuticals or aids and appliances (equipment) under Part 9 of the LSS Rules.
3.3 Reasonable expenses in relation to pharmaceuticals will not generally include:
3.3.1 expenses that form part of the bed day fee in a hospital or inpatient rehabilitation facility;
3.3.2 shampoo or other items for personal grooming;
3.3.3 any other items able to be purchased from a pharmacy such as cosmetics, food and beverages; and
3.3.4 any pharmaceuticals that are illegal.
4.1 Where relevant (3.1.1 above) the LSA requires that pharmaceuticals must be prescribed by an appropriate medical practitioner registered with the AHPRA (or other appropriate professional body if the participant resides outside Australia) and must be provided by an appropriate pharmacist registered with the appropriate professional body (unless the participant resides outside Australia).
4.2 The participant’s treating medical practitioner may be requested to provide a list of pharmaceuticals related to the motor vehicle injury before the LSA is able to assess a participant’s needs for or in connection with pharmaceuticals.
5.1 The LSA considers necessary and reasonable treatment, care and support needs in connection with fertility treatment when the need for the assisted fertility treatment arises from the motor vehicle injury.
5.2 The LSA considers necessary and reasonable treatment, care and support needs in connection with fertility treatment to include:
5.2.1 fertility medication, ovulation induction or assisted insemination;
5.2.2 in-vitro fertilisation (IVF) treatment;
5.2.3 assisted ejaculation or obtaining sperm by other means such as testicular aspiration;
5.2.4 egg and sperm storage (individual circumstances to be considered);
5.2.5 obtaining donor eggs or sperm, including retrieval and storage, in circumstances where a participant is unable to produce viable eggs or sperm because of the motor vehicle injury; and
5.2.6 fertility counselling only as an inclusive component of the assisted fertility intervention for a participant and or their partner.
5.3 Necessary and reasonable treatment and care needs in connection with assisted fertility treatment do not include:
5.3.1 surrogacy, whether commercial or altruistic surrogacy;
5.3.2 assisted fertility intervention to address the fertility needs of the participant's partner if these are not the result of the motor vehicle injury;
5.3.3 any treatment or service where there is no objective evidence that the treatment or service is safe and effective;
5.3.4 any treatment or service that is experimental or not consistent with intervention offered to the general community;
5.3.5 any treatment or service that is not consistent with the guidelines of the assisted fertility treatment facility that the participant and their partner are attending;
5.3.6 any treatment or service that is inconsistent with relevant State or Commonwealth legislation; and
5.3.7 any assisted fertility treatment that is elective, or for medical conditions not related to the motor vehicle injury.
5.4 The reasonable expenses in relation to the participant’s assessed treatment, care and support needs in relation to assisted fertility treatment will not generally include:
5.4.1 the costs of raising a child; and
5.4.2 the costs associated with the pregnancy and birth of the baby conceived through assisted fertility treatment that are not related to the motor vehicle injury, such as obstetrician, hospital, midwife and/or other birthing costs.
5.5 The LSA considers necessary and reasonable treatment, care and support needs in connection with fertility treatment to include a reasonable number of IVF treatments per pregnancy attempt, in line with usual practice. The LSA will consider up to 5 stimulated cycles per pregnancy attempt to be necessary and reasonable (in accordance with the relevant annual report of the Australian & New Zealand Assisted Reproduction Database). If over 5 stimulated cycles are required, the LSA will consider the recommendation of the fertility medical specialist in determining whether further treatments are necessary and reasonable.
5.6 The LSA will consider it necessary and reasonable for both the participant and the participant’s partner to receive assisted fertility treatment, when it is the participant’s fertility status that is affected by the motor accident injury.
6.1 Information required by the LSA to assess a participant’s treatment, care and support needs in connection with assisted fertility treatment may include:
6.1.1 information about the relationship between the participant’s need for fertility treatment and their motor vehicle injury;
6.1.2 the likely permanence of the participant's compromised fertility status;
6.1.3 the nature and extent of treatment that the participant and partner will require;
6.1.4 the anticipated outcome and success rate of the assisted fertility treatment;
6.1.5 information about any other treatment or services that may impact on the proposed treatment; and
6.1.6 any other relevant information relating to the participant's or their partner’s fertility.