Medical and pharmaceutical treatment guideline

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View our individual guidelines to focus on the topics that matter to you. These are also available in plain language versions which are easier to understand (called MyGuides).

Medical and pharmaceutical treatment guideline (PDF, 322KB)

MyGuide2: medical treatment and supplies (PDF, 155KB)

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  • Defined terms are shown throughout in bold underlined text when they first appear.

    Allied health provider means allied health professionals regulated under the Health Practitioner Regulation National Law (Queensland) including:

    • medical radiation practitioners
    • occupational therapists
    • optometrists
    • osteopaths
    • pharmacists
    • physiotherapists
    • podiatrists
    • psychologists.

    Allied health providers also include persons who are a part of a self-regulated allied health profession.

    Assisted fertility treatment is treatment provided by, or under the supervision of a fertility medical specialist and includes:

    • fertility medication, ovulation induction or assisted insemination
    • in-vitro fertilisation (IVF) treatment
    • assisted ejaculation or obtaining sperm by other means such as testicular aspiration
    • egg and sperm storage
    • obtaining donor eggs or sperm, including retrieval and storage
    • fertility counselling as part of the assisted fertility intervention for a participant
    • all other forms of assisted fertility or assisted reproductive technology

    Fertility medical specialist is a medical practitioner who is appropriately qualified to provide advice about infertility, including a specialist in reproductive endocrinology and infertility.

    Health Practitioner Regulation National Law is Queensland’s modified application of Health Practitioner Regulation National Law (Queensland) under the Health Practitioner Regulation National Law Act 2009 (Qld).

    Medical practitioner is a person registered by the Medical Board under the Health Practitioner Regulation National Law (Queensland) to practice medicine in Australia (other than student registration).

    Medicare Benefits Schedule is a list of services maintained by the Australian Government.

    Public sector health service means any service provided by, or under any of the following:

    State emergency services include but are not limited to services provided by Queensland Ambulance Service, Queensland Fire and Emergency Service and Queensland Police Service.

    Telehealth is a consultation with a healthcare provider by phone or video call, or similar technology.

  • The NIISQ Agency will identify a participant’s needs for (or relating to) medical treatment and pharmaceuticals and will fund treatment in accordance with the National Injury Insurance Scheme (Queensland) Act 2016, the National Injury Insurance Scheme (Queensland) Regulation 2016, this guideline, and other relevant guidelines.

    There is a plain language version of this guideline which is shorter and uses simpler words. To access it, view MyGuide 2 – Medical treatment and supplies.

    This guideline should be read in conjunction with the:

    Medical treatment under the NIISQ

    Medical treatment covers a broad range of treatments, services, and medical appliances provided by, or prescribed by a medical practitioner and includes:

    • consultations with medical practitioners
    • surgery
    • diagnostic services, including diagnostic radiology
    • medical treatment provided by a medical practitioner, including small procedures
    • other types of medical treatment including pain management and assisted fertility treatment.

    Medical treatment includes services associated with providing medical treatment, including treatment plans, reports, and case conferences.

    Pharmaceuticals under the NIISQ

    Pharmaceuticals are medicines and medications available from a chemist or pharmacy. Pharmaceuticals include:

    • prescription medicines
    • over-the-counter medicines
    • complementary medicines, including vitamins and mineral supplements
    • medical devices and other items, including bandages, medical gloves, and continence support products.

  • Approval for medical treatment and pharmaceuticals must be provided by the NIISQ Agency before treatment is provided, or pharmaceuticals are purchased.

  • The National Injury Insurance Scheme (Queensland) Act 2016 and the National Injury Insurance Scheme (Queensland) Regulation 2016 describe how the NIISQ Agency decides whether a medical and pharmaceutical treatment is necessary and reasonable, and can be funded.

    The NIISQ Agency has published a guideline which explains how it decides whether a support is necessary and reasonable, and is for a treatment, care and support need (see: Necessary and reasonable guideline).

    When the NIISQ Agency assesses whether a participant’s needs for medical treatment and pharmaceuticals are necessary and reasonable, it will give particular attention to the following:

    • whether the medical treatment and/or pharmaceuticals will benefit the participant, including a consideration of how any risks are weighed against the benefit
    • whether the medical treatment or pharmaceuticals are consistent with other treatment, care and support received by the participant
    • whether there is evidence that supports the effectiveness of the medical treatment or pharmaceuticals (see: evidence-based interventions).

    The NIISQ Agency will fund the associated transport costs incurred by a participant for attending necessary and reasonable medical treatment (see: Transport-related expenses in the Attendant care and support services guideline).

  • In assessing a participant’s needs for medical treatment and pharmaceuticals, the NIISQ Agency will ordinarily require information from a medical practitioner, allied health provider, registered nurse, clinical nurse or nurse practitioner to assist the NIISQ Agency to decide whether it is necessary and reasonable.

    Identifying a participant’s treatment, care and support needs is done in collaboration with the participant, their family and/or other informal supports, and providers.

    Information required by the NIISQ Agency to assess needs

    The NIISQ Agency will generally require any existing information about the participant’s accepted injury.

    Where information about a participant’s needs for medical treatment is unavailable, the NIISQ Agency may fund a consultation including a written report provided by a medical practitioner, and where relevant, an allied health provider who has treated the participant, as well as diagnostic services.

    The information required by the NIISQ Agency generally includes matters which relate to:

    • whether any recommended medical treatment relates to a participant’s accepted injury, and if partially, the extent to which pre-existing or co-existing conditions have contributed to the participant’s need for medical treatment
    • the benefits that the treatment will have for the participant, including how any benefits are weighed against the risks of any treatment recommended by the medical practitioner
    • whether there are any alternatives to the medical treatment
    • whether the treatment is for the participant and not for another person (with the exception of certain assisted fertility treatments)
    • if the medical practitioner is not the person who can provide the medical treatment, information about an appropriate provider (referral) for another medical practitioner who can provide the medical treatment
    • information about the costs of the medical treatment, including Medicare Benefits Schedule numbers
    • for pharmaceuticals, whether:
      • pharmaceuticals have been prescribed or recommended by a medical practitioner, allied health provider, registered nurse, clinical nurse or nurse practitioner
      • documentation outlining the purpose of medications related to the accepted injury.

    Where medical treatment is not on the Medicare Benefits Schedule

    The NIISQ Agency will generally only consider funding medical treatment where the treatment is listed on the Medicare Benefits Schedule and is consistent with any conditions, guidance or other requirements specified by the Austrailan Government Department of Health and Aged Care.

    Where treatment is recommended for a participant which is not listed on the Medicare Benefits Schedule, the NIISQ Agency may require additional evidence provided by a medical practitioner, including a medical specialist published on the Specialists Register, as maintained and updated by the Australian Health Practitioner Regulation Agency.

    New or innovative medical treatment

    On a case-by-case basis, the NIISQ Agency may fund new and innovative medical treatment for a participant where the treatment is consistent with the best-available research evidence. The NIISQ Agency uses the nationally-recognised Clinical Framework for the Delivery of Health Services (see: Necessary and reasonable guideline).

    New or innovative medical treatment excludes treatment that is a part of a clinical trial or is experimental treatment (see: Limitations on funding for medical and pharmaceutical treatment).

    Where a medical practitioner has recommended new or innovative medical treatment, the NIISQ Agency may require additional information to assess whether the treatment can be funded.

    The NIISQ Agency will not fund treatment where there is limited evidence relating to its safety or effectiveness or is otherwise inconsistent with best practices for people with injuries comparable to the participant’s accepted injury.

    Medical treatment and pharmaceutical supports must be provided by an appropriate provider

    Medical practitioners do not need to be a registered provider under the National Injury Insurance Scheme (Queensland) Act 2016, however, all medical practitioners must be health professionals regulated under the national regulation administered by the Australian Health Practitioner Regulation Agency.

    The NIISQ Agency expects medical practitioners to comply with their legal and professional obligations under the Health Practitioner Regulation National Law including (but not limited to):

    • maintaining appropriate professional indemnity insurance
    • complying with the shared Code of conduct published on the Australian Health Practitioner Regulation Agency’s website.

    Similar requirements apply to allied health professionals, where all allied health professionals must comply with their obligations under the Health Practitioner Regulation National Law or self-regulatory frameworks (where applicable), including any requirements specified by the Australian Government Department of Health and Aged Care.

    Prescription medicines and over-the-counter medicines must be provided by an allied health professional who is a Pharmacist.

    Providing telehealth services

    When deciding whether medical treatment delivered via telehealth is necessary and reasonable, the NIISQ Agency will give particular consideration to:

    • whether delivery of the support is appropriate for the participant in comparison to alternatives(i.e. face-to-face consultations or appointments). Providers are encouraged to use telehealth when it is clinically appropriate for the participant, and the need for telehealth relates to the participant’s accepted injury
    • whether the provider is able to provide the support via telehealth (including that the provider has the necessary information technology, and can ensure that the participant’s information is secure)
    • whether the participant is able to use telehealth services (the NIISQ Agency does not fund computers, tablets, internet connections which are everyday items).

    All rehabilitation supports provided by telehealth must be provided in line with peak body telehealth guidelines, and Australian Government and state policies including:

  • Assisted fertility treatment

    If a participant’s fertility has been affected by their accepted injury, the NIISQ Agency will fund fertility treatment for the participant.

    The NIISQ Agency may fund assisted fertility treatment when:

    • infertility is a result of a participant’s accepted injury
    • fertility treatment is supported by a referral from a fertility medical specialist and
    • a fertility medical specialist has prescribed fertility treatment for a participant.

    Fertility treatment will be assessed by the NIISQ Agency to decide whether it is necessary and reasonable, treatment, care and support. In addition to the general matters which the NIISQ Agency will consider (see: Assessment of needs for medical treatment and pharmaceuticals and Supporting a participant who needs medical treatment and pharmaceuticals), the NIISQ Agency will consider:

    • whether the treatment is safe and effective based on independent, high-quality evidence
    • whether the treatment is experimental, or is inconsistent with general medical treatments which are publicly available
    • whether the treatment is consistent with the guidelines of the assisted fertility treatment facility that the participant attends
    • whether the treatment relates to medical conditions which are not related to the participant’s accepted injury (for example, pre-implantation genetic diagnosis)
    • whether the treatment is counselling services for a participant’s partner which is not provided as part of fertility treatment
    • information about the relationship between the participant’s need for fertility treatment and their accepted injury
    • the likely permanence of the participant’s compromised fertility status
    • the nature and extent of treatment that the participant requires, including how the treatment impacts a participant’s partner
    • the anticipated outcome and success rate of the assisted fertility treatment
    • information about any other treatment or services that may impact on the proposed treatment
    • any other relevant information relating to the participant’s or their partner’s fertility.

    Storage services for fertility treatment

    The length of time that the NIISQ Agency will fund egg and sperm storage is based on advice provided by a fertility medical specialist.

    Services related to donor eggs or sperm, including retrieval and storage, is only funded under the NIISQ when a participant cannot produce viable eggs or sperm because of their accepted injury.

    In-vitro fertilisation (IVF)

    The NIISQ Agency will ordinarily fund five stimulated cycles per pregnancy attempt when IVF fertility treatment is supported by a fertility medical specialist.

    Where a participant may need more than five stimulated cycles, the NIISQ Agency will obtain advice from a fertility medical specialist to decide whether additional attempts can be funded under the NIISQ.

  • The NIISQ Agency does not reimburse medical treatment or pharmaceuticals which are:

    The NIISQ Agency is not required to fund medical and pharmaceutical treatment provided as part of a medical trial or on another experimental basis.

  • The following is generally not considered necessary and reasonable treatment, care and support:

    • medico-legal assessments, reports, or other services related to a claim
    • services and pharmaceuticals which are not included in the bed fee for treatment received by a participant as part of a public sector health service
    • treatment which is provided on an experimental or trial basis (see: Limitations on funding for medical treatment and pharmaceuticals)
    • anything which is required due to the effects of: experimental treatment, treatment provided as part of a clinical trial, or any other treatment which has not been approved by the NIISQ Agency
    • in relation to assisted fertility treatment, the NIISQ Agency will generally not fund:
      • surrogacy
      • fertility treatment that is not related to a participant’s accepted injury
      • costs associated with raising a child
      • birthing costs which are not related to a participant’s accepted injury (for example, hospital fees, midwife and other birthing costs)
    • general pharmacy items and other pharmaceutical expenses including:
      • toilet paper, laundry products, shampoo or other items for personal grooming
      • cosmetics, food and beverages
      • sunscreen, which is regarded as a standard household cost unless prescribed for scar management
      • contraceptive prescriptions
    • medical treatment and pharmaceuticals provided by a provider who is outside Australia.

Last updated: July 2024