1.1 This Part applies for the purposes of Part 4 of the Act.
1.2 The LSA will only pay for necessary and reasonable treatment, care and support needs that relate to the motor vehicle injury.
2.1 The LSA will pay for the participant’s necessary and reasonable treatment, care and support needs related to the motor vehicle injury, where the LSA is satisfied that:
2.1.1 there is clinical justification for services;
2.1.2 there is evidence that the service is necessary and reasonable in relation to the motor vehicle injury;
2.1.3 the service is likely to be effective and achieve or maintain a measurable functional improvement; and
2.1.4 the service promotes progress towards functional autonomy, participation in community life and the economy.
2.2 Treatment care and support services included in the bed day fee when the participant is an inpatient will not be paid for separately.
2.3 Treatment, care and support are defined in Part 1 section 4 of the Act to include:
a. medical treatment, including pharmaceuticals;
b. dental treatment;
d. ambulance transportation;
e. respite care;
f. attendant care and support services;
g. aids and appliances;
i. education and vocational training;
j. home and transport modification;
k. workplace modification;
l. such other kinds of treatment, care, support or services as may be prescribed by the regulations; and
m. such other kinds of treatment, care, support or services as may be determined by the LSA (either generally, for specified classes of cases, or for a particular person).
2.4 The LSA may, in exceptional cases, determine funeral services to be within the ambit of Rule 2.3 (m) above.
2.5 There may be items that are related to the motor vehicle injury that are necessary and reasonable in the circumstances, but are not regarded as treatment, care, support or services under the scope of the Act, regulations or these Rules. In this case, the LSA will not pay for any such services or supports, but may work with participants, service providers and other authorities to facilitate access to such services where there may need to be congruence with treatment, care, support or services funded by the LSA.
3.1 Treatment, care or support will be dealt with on a case by case basis and decided taking into account the ‘necessary and reasonable’ criteria outlined below.
3.2 If a specific service (incorporating treatment, care, support or items of equipment) is not the subject of a specific section in these Rules, the LSA may pay the costs of that service, if it is determined by the LSA to be necessary and reasonable in the circumstances.
3.3 In determining whether treatment, care and support is ‘necessary and reasonable’ the LSA will consider a number of factors, including the following:
a. benefit to the participant;
b. appropriateness of the service;
c. appropriateness of the provider;
d. cost effectiveness; and
e. relationship of the services to the injuries sustained in the accident.
3.4 Each of these factors involves several considerations, detailed below. No one consideration is determinative or required.
Benefit to the participant
3.5 A proposed service will be considered by the LSA to be of benefit to the participant if:
3.5.1 it can be demonstrated that the proposed service relates to the participant’s goals;
3.5.2 the outcome of the service will progress or maintain the participant’s recovery or participation;
3.5.3 it is a service or related service which has been provided in the past with positive results or outcomes;
3.5.4 the service has a specific goal or goals, and expected duration and expected outcome/s; and
3.5.5 any potential risk is sufficiently offset by the expected benefits from providing the service.
Appropriateness of service
3.6 The proposed service will be considered by the LSA to be appropriate for the participant if:
3.6.1 it is consistent with the participant’s current medical or rehabilitation management;
3.6.2 it relates to the participant’s goals in the MyPlan (if relevant);
3.6.3 it is in keeping with current clinical practice, evidence-based practice and/or clinical rules;
3.6.4 a similar service is not currently provided;
3.6.5 there is good evidence that the requested service is effective;
3.6.6 it is consistent with other services currently being offered or proposed;
3.6.7 the cost is reasonable in the context of the person’s injury and severity assessment; and
3.6.8 it is new or innovative, there is sufficient rationale for offering it and measures exist to quantify its outcomes.
Appropriateness of provider
3.7 The proposed service provider will be considered by the LSA to be appropriate if they are:
3.7.1 qualified and appropriately experienced to provide the service;
3.7.2 registered with the LSA (if applicable);
3.7.3 appropriate considering the participant’s age, ethnicity and any cultural and linguistic factors;
3.7.4 expected to be found acceptable by the participant; and
3.7.5 readily accessible by the participant.
3.8 The proposed service will be considered by the LSA to be cost effective if:
3.8.1 consideration has been given to the long-term compared to the short-term benefits, taking into account evidence-based practice, clinical experience and costs;
3.8.2 the cost of the proposed service is comparable to those charged by providers in the same geographical area or clinical area;
3.8.3 the service is required because other services or equipment are not available or not appropriate;
3.8.4 lease or rental costs of equipment or modifications have been carefully considered in comparison to purchase costs; and
3.8.5 any realistic alternatives to purchasing equipment/modifications have been considered, including the impacts of technology advances and changes to participant’s needs over time.
Relationship to motor vehicle injuries
3.9 The proposed services will be considered by the LSA to be related to the motor vehicle injuries if:
3.9.1 there is sufficient evidence to demonstrate that the service relates to the motor vehicle injuries including exacerbation of pre-existing injuries or conditions; and
3.9.2 the impact of time since injury, subsequent injuries and co-morbidities have been taken into account.
4.1 These Rules may place limits on the provision of particular treatment, care and support services. The LSA may determine such monetary or other limits from time to time and publish any such determination in the Gazette and on its website.
4.2 The LSA will not pay for treatment, care and support costing more than the maximum amount for which the LSA is liable in respect of:
4.2.1 any claim for fees for services not provided at public hospitals, as published by the Minister in the Gazette under section 41(3) of the Act,
4.2.2 services or expenses that are not treatment, care and support under the scope of the Act, in particular under section 28(1), such as gratuitous services, ordinary costs of raising a child, services not provided by an approved provider or provided in contravention of these Rules.
4.3 The LSA will not pay for economic loss, capital items, rent or bond for rental properties, lost wages, maintenance and income support, assistance to keep a business open, such as paying for temporary staff to do a participant’s job; additional expenses incurred during inpatient or outpatient treatment or rehabilitation, such as food, laundry, newspapers and magazines.
4.4 The LSA will not pay for experimental or non-established treatment where the LSA is not satisfied that:
4.4.1 peer reviewed journal articles demonstrate efficacy;
4.4.2 interventions are widely supported by practitioners in the field;
4.4.3 interventions have progressed past the early stages of clinical trial; or
4.4.4 there is an MBS item number (for medical treatment, procedures and surgery).
4.5 The LSA will not provide treatment, care and support for any complications arising out of any experimental or non-established treatment that is undertaken without the LSA’s approval.