Medicare Rebate for Prostate MRI in Australia
On July 1st 2018 a Medicare rebate with introduced for prostate MRI scans. The rebate can be claimed under some conditions and at some locations. When referring a patient to radiology a Urologist will be able to determine ahead of time if the patient is eligible for the rebate if they attend a radiology provider with a rebatable MRI scanner installed.
Information herein is intended to be informational in nature and should not be seen as medical advice. Information about rebates and indications is correct at the time of writing but may change.
What is an MRI?
Magnetic Resonance Imaging (MRI) is a non-invasive imaging technique that uses magnetism and electromagnetic waves to image the human body. Unlike other imaging
modalities such as CT and X-Ray, MRI does not use radiation in order to generate images. MRI can be used to image many parts of the human body and is known for its ability to image soft tissue with a high resolution.
Multi-Parametric MRI of the Prostate
Multi-Parametric MRI (mpMRI) is a series of MRI scans of the prostate each of which captures different information. Structural and functional information about the prostate is captured through multiple MRI sequences.
These images are then reviewed by a radiologist and reported back to the referring clinician.
Can I get the Prostate MRI rebate?
If you meet the clinical criteria, as defined by Medicare, for the MRI rebate you can undertake a rebatable MRI of the prostate once in any 12 month period. As a Urologist or oncologist are the only clinicians able to refer for a rebatable mpMRI they will determine if you meet the clinical criteria when providing the referral. The latest copy of the criteria is available here.
You must fulfill one of the following criteria to receive the rebate.
1: Have a digital rectal examination (DRE) which is suspicious for prostate cancer.
A digital rectal examination is an in personal physical examination in which the clinician feels for abnormalities in the prostate through the rectum. The clinician is at his or her clinical discretion to determine if the DRE results are abnormal.
2: A person less than 70 years with at least 2 PSA tests performed within an interval of 1-3 months which are greater than 3.0 ng/ml, and the free-to-total PSA ratio is less than 25% or the repeat PSA exceeds 5.5 ng/ml.
3: A person less than 70 years whose risk of developing prostate cancer based on family history is at least double the average risk and has at least 2 PSA tests performed within an interval of 1-3 months where both are greater than 2.0 ng/ml and the free to total PSA rate is less than 25%.
A first degree relative with prostate cancer or a suspicion of a BRCA1 or BRCA2 mutation is considered to be a positive family history. You can discuss your family history with your clinician to determine if this is the case or read more here.
4: In a person aged 70 years or older with at least two PSA tests performed within an interval of 1-3 months that are greater than 5.5 ng/ml and the free to total PSA ratio is less than 25%.
There is an additional code for men who are on an Active Surveillance program. This is a clinical determination by a managing Urologist.
Where can I get the rebate?
Not all MRI centres are eligible for the mpMRI rebate for prostate cancer. It is important that you or your clinician contact the imaging centre prior to booking. This will allow you to understand if a rebate is possible. Booking at a non-rebatable MRI will result in an out of pocket fee for the imaging. You can find a list of Medicare eligible MRIs here.
An out of pocket fee does not stop you from getting the scan, but will involve payment.
Does Maxwell Plus help to organise Prostate MRI scans?
Yes, if you require an MRI whilst a Maxwell Plus member your clinician will assist in the booking process and determine if you are eligible for the rebate.
A Urologist must order mpMRI for the prostate. Maxwell Plus members will only be sent for one if it is a resulting outcome of your personalised testing pathway. This is based on your prior test results whilst a Maxwell Plus member.
Current members can request further information on this topic through the in app support channel.