Pre-Auth Queue
Margaret Hughes
Medibank Gold Hospital · Mr A. Okafor, FRACS
Pre-auth — Total knee replacement (R) — admission 2 Apr
David Tran
HCF Silver Plus · Dr P. Mensah
Pre-auth — Cataract extraction (L)
Aisha Rahman
Bupa Gold · Ms L. Caruso
Pre-auth — Laparoscopic cholecystectomy
From: Mr A. Okafor, FRACS <rooms@northortho.com.au>
Pre-auth request — Total knee replacement, right
Dear Pre-authorisation team,
Requesting pre-authorisation for Mrs Margaret Hughes (Medibank #9042 1183, Gold Hospital, joined 2017) for an elective right total knee replacement, MBS item 49518.
Diagnosis: severe osteoarthritis, right knee (M17.11). Imaging confirms Kellgren-Lawrence Grade 4, bone-on-bone medial compartment. Conservative management over 14 months — physiotherapy, NSAIDs, and an intra-articular corticosteroid injection (Jul 2025) — has failed to control pain or restore function.
Planned admission Northern Private Hospital, 2 April 2026. Prosthesis: cemented cobalt-chrome knee system (Prostheses List billing code KN1042).
Kind regards,
Mr A. Okafor
Extracted Eligibility Criteria
Patient
Margaret Hughes, DOB 14/03/1958
referral
Membership
Medibank Gold Hospital, #9042 1183 (joined 2017)
referral
Procedure
Total knee replacement, right — MBS 49518
referral
Diagnosis
Osteoarthritis, right knee (ICD-10 M17.11)
referral
Indication
Bone-on-bone medial compartment, function-limiting
imaging report
Imaging
Kellgren-Lawrence Grade 4 (weight-bearing X-ray)
imaging report
Conservative
14 mo physio + NSAIDs + corticosteroid injection
GP notes
Provider
Mr A. Okafor, FRACS — Provider 245718GH
referral
Facility
Northern Private Hospital — admission 2 Apr 2026
referral
Prosthesis
Cemented Co-Cr knee system (PL code KN1042)
referral
Criteria-match confidence
Draft Submission
Surgeon fee (MBS 49518)
$2,180
Anaesthetics (MBS 21214)
$920
Hospital & theatre
$18,400
Prosthesis (PL KN1042)
$6,850
Benefit payable
$28,350
Estimated patient gap: $1,240
Insurer SLA: 5 business days
Prosthesis KN1042 not on Medibank no-gap list — confirm gap with patient before submit