Schedule 5 - Appendix A - Surgically Implanted Prostheses

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CARDIO-THORACIC Billing Code Product Further Size Notations BA091 Impra PTFE Vascular Grafts ePTFE Cardiovascular, Patch 0.6mm, 50 x 75mm Rectangular BA092 Impra PTFE Vascular Grafts ePTFE Cardiovascular, Patch 0.6mm, 50 x 150mm Rectangular BA093 Impra PTFE Vascular Grafts ePTFE Cardiovascular, Patch 0.6mm, 30 x 30mm, 10 x 90mm, 30 x 60mm Rectangular, Patch 0.4 Oval, Rectangular BA095 Impra PTFE Vascular Grafts ePTFE Cardiovascular, Patch 0.6mm, 25 x 150mm Rectangular Baxter Healthcare Pty Ltd Annuloplasty Rings BX159 Baxter Sterile Grafts, Implants & Carpentier-Edwards Classic 24mm-40mm Prostheses, Non-Animal Origin Annuloplasty Ring. Composition: Annuloplasty: Ring-Mitral Ring with Titanium Alloy; Silicone Rubber; Holder; Mitral Cosgrove-Edwards Polyester Fabric Annuloplasty System Model 4600; Carpentier-Edwards Physio Classic Annuloplasty Ring-Tricuspid Annuloplasty Ring. Composition: Elgiloy Bands; Polyester Film Strips; Silicone Rubber; Polyester Cloth, Cosgrove-Edwards Annuloplasty Band. Composition: Silicone Rubber; Polyester Cloth. Carpentier-Edwards Tricuspid Ring. Composition: Titanium Alloy; Silicone Rubber; Polyester Fabric Grafts, Dura, Biological BX164 Baxter Augmentation / Substitution Edwards Pericardial Patch. Bovine 10cm x 16cm Material, Human or Animal Origin, Pericardium. Sterile Pericardial Patch. Page 2 of 638
CARDIO-THORACIC Billing Code Product Further Size Notations Prostheses, Cardiac Valve, Artificial BX160 SE SIL Ball Valve Aortic Models Starr Edwards - Silastic Ball Valve. 16mm-34mm 1200/1260, SE SIL Ball Valve Mitral Composition: Stellite Alloy No. 21; Model 6120 Polytetrafluroethelyne; polypropylene cloth; Silicone rubber (contains 2% by weight Prostheses, Cardiac Valve, Biological BX161 CE Supra Annular Aortic Valve Model Carpentier-Edwards SAV 19mm-33mm 2650 Carpentier-Edwards S.A.V Bioprosthesis. Composition: Bioprosthesis Model 6650 Mitral Porcine Valve; Elgiloy Alloy; Silicone Rubber, BX162 Carpentier-Edwards Perimount Carpentier-Edwards Pericardial Models 2900/6900 19-33mm, Pericardial Bioprosthesis - Models Bioprosthesis. Composition: Model 6900P 25, 27, 29, 31, 33mm 2900/6900 Carpentier-Edwards Bovine Pericardium; Elgiloy Alloy; Perimount Plus Pericardial Silicone Rubber, Bioprosthesis Mitral - Model 6900P BX163 Baxter Edwards Prima Plus Stentless Edwards Prima Plus. Porcine Valve; 19mm-29mm Bioprosthesis Model 2500P Woven Polyester Cloth. Prosthetic Heart Valve Biotronik Australia Pty Ltd Defibrillators, Automatic, Implantable BT022 Biotronik Australia Belos VR Single chamber ICD, rate responsive One size only Implantable Cardioverter Defribrillator pacing BT023 Tachos Model DR335572 Implantable Dual chamber ICD, rate responsibe One size only - Cardioverter Defribrillator pacing Leads, Implantable Defibrillator BT014 Kainox RV 75 Implantable Defibrillator 75 cms 100,18 cms 100,16 cms endocardial shock lead with sensing 100,13 cms 75,18 cms and pacing. SL 100/18, SL 100/16, Page 3 of 638
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Schedule 5 - Appendix A - Surgically Implanted Prostheses

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