• 1.1The LSA will pay for necessary and reasonable medical treatment, to the extent it is directly related to the Motor Vehicle Injury including:
    • 1.1.1medical and surgical treatment;
    • 1.1.2Pharmaceutical Products;
    • 1.1.3specialised liquid nutrition (gastronomy feeds);
    • 1.1.4diagnostic tests such as imaging services;
    • 1.1.5inpatient or outpatient treatment provided by a hospital;
    • 1.1.6medical treatment, reports, case conferences or other contact with other professionals treating the Participant; and
    • 1.1.7other specialised medical treatments considered to be necessary and reasonable by the LSA.

  • 2.1Information required by the LSA to assess a Participant’s TCS needs in connection with medical treatment may include:
    • 2.1.1information relating to the medical treatment including the MBS number where applicable;
    • 2.1.2information about pre-existing or co-existing medical conditions;
    • 2.1.3information 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;
    • 2.1.4clinical assessments and reports;
    • 2.1.5justification for the proposed treatment, including the relationship to the Motor Vehicle Injury; necessary and reasonable criteria; and
    • 2.1.6justification for the treatment process, including any associated medical treatment as part of an overall treatment plan.
  • 2.2The following procedures are to be followed when assessing TCS needs in connection with medical treatment:
    • 2.2.1the medical treatment must be prescribed by an Appropriately Qualified Medical Specialist or medical practitioner registered with the AHPRA (or other appropriate professional body if the Participant resides outside Australia); and
    • 2.2.2the treatment must be approved by the LSA prior to commencement in all circumstances, unless the treatment is deemed urgent by the treating practitioner (e.g. life threatening); and
    • 2.2.3the medical practitioner or Medical Specialist, when providing medical services, should reference the relevant MBS item number or the corresponding AMA item number.

  • 3.1The LSA will pay for necessary and reasonable Pharmaceutical Products when they are directly related to the Motor Vehicle Injury and:
    • 3.1.1in relation to prescribed pharmaceuticals, are prescribed by an appropriate medical practitioner registered with the AHPRA (or other appropriate professional body if the Participant resides outside Australia) and are provided by an appropriate pharmacist registered with the appropriate professional body (unless the Participant resides outside Australia); or
    • 3.1.2in relation to other Pharmaceutical Products (e.g. over the counter medications, prescribed vitamins and supplements, topical skin creams, wound care items and consumables), prescribed by an Appropriately Qualified health practitioner.
  • 3.2The 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.

  • 4.1The LSA considers necessary and reasonable TCS needs in connection with fertility treatment when the need for the assisted fertility treatment arises directly from the Motor Vehicle Injury.
  • 4.2The LSA considers necessary and reasonable TCS needs in connection with fertility treatment to include:
    • 4.2.1fertility medication, ovulation induction or assisted insemination;
    • 4.2.2IVF (in-vitro fertilisation) treatment;
    • 4.2.3assisted ejaculation or obtaining sperm by other means such as testicular aspiration;
    • 4.2.4egg and sperm storage (individual circumstances to be considered);
    • 4.2.5obtaining 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
    • 4.2.6fertility counselling only as an inclusive component of the assisted fertility intervention for a Participant and or their partner.
  • 4.3The LSA considers necessary and reasonable TCS 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.
  • 4.4The 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 Vehicle Injury.

  • 5.1Information required by the LSA to assess a Participant’s TCS needs in connection with assisted fertility treatment may include:
    • 5.1.1information about the relationship between the Participant’s need for fertility treatment and their Motor Vehicle Injury;
    • 5.1.2the likely permanence of the Participant's compromised fertility status;
    • 5.1.3the nature and extent of treatment that the Participant and partner will require;
    • 5.1.4the anticipated outcome and success rate of the assisted fertility treatment;
    • 5.1.5information about any other treatment or services that may impact on the proposed treatment; and
    • 5.1.6any other relevant information relating to the Participant's or their partner’s fertility.

  • 6.1The LSA does not pay for:
    • 6.1.1fees associated with medico-legal reports or any medical reports not requested by the LSA;
    • 6.1.2additional expenses incurred while receiving inpatient or outpatient medical treatment such as food, magazines, phone line rental and phone calls;
    • 6.1.3a medical 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;
    • 6.1.4a medical treatment or service without a MBS code;
    • 6.1.5a treatment or service where there is no published evidence relating to its safety or effectiveness;
    • 6.1.6non-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;
    • 6.1.7a 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 4.4, or when a Family member is receiving counselling services in accordance with Part 6 Rule 2.2; and
    • 6.1.8a treatment or service that is of no clear benefit to the Participant.
  • 6.2Reasonable expenses in relation to Pharmaceutical Products will not generally include:
    • 6.2.1expenses that form part of the bed day fee in a hospital or inpatient Rehabilitation facility;
    • 6.2.2shampoo or other items for personal grooming;
    • 6.2.3any other items able to be purchased from a pharmacy such as cosmetics, food and beverages;
    • 6.2.4any Pharmaceutical Products that are not related to medical conditions/ injuries resulting directly from the Motor Vehicle Accident; and
    • 6.2.5any Pharmaceutical Products that are illegal.
  • 6.3Necessary and reasonable Treatment, care and support needs in connection with assisted fertility treatment does not include:
    • 6.3.1surrogacy, whether commercial or altruistic surrogacy;
    • 6.3.2assisted fertility intervention to address the fertility needs of the Participant's partner if these are not the result of the Motor Vehicle Injury;
    • 6.3.3any treatment or service where there is no objective evidence that the treatment or service is safe and effective;
    • 6.3.4any treatment or service that is experimental or not consistent with intervention offered to the general community;
    • 6.3.5any treatment or service that is not consistent with the guidelines of the assisted fertility treatment facility that the Participant and their partner are attending;
    • 6.3.6any treatment or service that is inconsistent with relevant State or Commonwealth legislation;
    • 6.3.7any assisted fertility treatment that is elective, or for medical conditions not related to the Motor Vehicle Injury;
    • 6.3.8the costs of raising a child or children; and
    • 6.3.9the 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 or other birthing costs.

Page last updated: 16 September 2022