ACC Treatment Injury Cover Assessment

During collaboration on the ACC treatment injury claim data report https://www.acc.co.nz/about-us/news-
media/latest-news/surgical-mesh-claim-data/, there were three outstanding questions. The response to these
questions are as follows:

How many surgical mesh-related claims had revision surgery?

Figure 1 Number of accepted surgical mesh-related claims with revision surgery by surgery type
groups

Surgical mesh-related claim counts with revision surgery

by surgery type groups from 1 July 2005 to 30 June 2017
With payment for elective surgery | Without payment for elective surgery

Total 387 (60%) 253 (40%)

POP and/or SUI repair 296 (78%) 84 (22%)

Hernia repair 75 (34%) 145 (66%)

Other mesh surgery 16 (40%) 24 (50%)

Claims with revision surgery have been identified where ACC made payment for elective surgery.
With payment for elective surgery is where ACC has paid for elective surgery as at 30 June 2017.
Without payment for elective surgery is where ACC has not paid for elective surgery as at 30 June 2017.

Figure 1 shows the number of surgical mesh-related claims with revision surgery (elective surgery) by surgery
type groups.

ACC data has identified three main surgery type groups for the surgical mesh-related claims, these are:

1. Pelvic Organ Prolapse (POP) and/or Stress Urinary Incontinence (SUI) repair
2. Hernia repair
3. Other mesh surgery (This includes mesh removal surgery, sling surgery for male urinary incontinence,
breast reconstruction and other reconstructive surgeries using mesh)

Of the 640 accepted surgical mesh-related claims; 60% (n=387) had elective surgery payments.

Of the 380 accepted surgical mesh-related claims for POP and/or SUI repair; 78% (n=296) had elective surgery
payments.

Of the 220 accepted surgical mesh-related claims for hernia repair; 34% (n=75) had elective surgery payments.

Of the 40 accepted surgical mesh-related claims for other mesh surgery; 40% (n=16) had elective surgery
payments.
Figure 2 Number of accepted surgical mesh-related claims with revision surgery for POP and/or SUI
by surgery types

Surgical mesh-related claim counts with revision surgery for POP and/or SUI repair
by surgery type from 1 July 2005 to 30 June 2017
With payment for elective surgery Without payment for elective surgery

Total 296 (78%) 84 (22%)

POP repair 114 (77%) 34 (24%)

SUI repair 72 (76%) 23 (24%)

POP & SUI repair 110 (80%) 27 (20%)

Claims with revision surgery have been identified where ACC made payment for elective surgery.
With payment for elective surgery is where ACC has paid for elective surgery as at 30 June 2017.
Without payment for elective surgery is where ACC has not paid for elective surgery as at 30 June 2017.

Figure 2 shows the number of surgical mesh-related claims with revision surgery (elective surgery) by surgery
type.

ACC data has identified three main surgery types for POP and/or SUI repair these are:

1. Pelvic Organ Prolapse (POP) repair

2. Stress Urinary Incontinence (SUI) repair
3. Combined Pelvic Organ Prolapse & Stress Urinary Incontinence (POP & SUI) repair (NOTE: Combined POP
& SUI repair refers to one single claim for one surgical event to treat both POP and SUI

Of the 380 accepted surgical mesh-related claims for POP and/or SUI repair; 78% (n=296) had elective surgery
payments.

Of the 148 accepted surgical mesh-related claims for POP repair; 77% (n=114) had elective surgery payments.

Of the 95 accepted surgical mesh-related claims for SUI repair; 76% (n=72) had elective surgery payments.

Of the 137 accepted surgical mesh-related claims for POP & SUI repair; 80% (n=110) had elective surgery
payments.

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Figure 3 Number of accepted surgical mesh-related claims with revision surgery for hernia repair
by surgery types

Surgical mesh-related claim counts with revision surgery for hernia repair
by surgery type from 1 July 2005 to 30 June 2017
With payment for elective surgery Without payment for elective surgery

Total 75 (34%) 145 (66%)

Groin hernia repair 26 (37%) 44 (63%)

Ventral hernia repair 45 (33%) 93 (67%)

Other hernia repair 4 (33%) 8 (67%)

Claims with revision surgery have been identified where ACC made payment for elective surgery.
With payment for elective surgery is where ACC has paid for elective surgery as at 30 June 2017.
Without payment for elective surgery is where ACC has not paid for elective surgery as at 30 June 2017.

Figure 3 shows the number of surgical mesh-related claims with revision surgery (elective surgery) by surgery
type.

ACC data has identified three main surgery types for hernia repair, these are:

1. Groin hernia repair

2. Ventral hernia repair
3. Other hernia repair (This includes hiatus hernia, perineal hernia, parastomal hernia or the hernia type is
unknown).

Of the 220 accepted surgical mesh-related claims for hernia repair; 34% (n=75) had elective surgery payments.

Of the 70 accepted surgical mesh-related claims for groin repair; 37% (n=26) had elective surgery payments.

Of the 138 accepted surgical mesh-related claims for ventral hernia repair; 33% (n=45) had elective surgery
payments.

Of the 12 accepted surgical mesh-related claims for other hernia repair; 33% (n=4) had elective surgery
payments.

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How many surgical mesh-related claims went to review and have a review outcome?
How long did the decision take from the time of the review to the review outcome?
Table 1 Number of surgical mesh-related claims with a review outcome

Surgical mesh-related claim counts by review outcome

from 1 July 2005 to 30 June 2017

Review outcome n %
Dismissed 13 37%
Quashed 5 14%
Withdrawn/settled 17 49%
Total 35 100%

Table 1 shows the 35 surgical mesh-related claims that went to review and have a review outcome.

ACC data has identified three main review outcomes on treatment injury decision, these are:

1. Dismissed: ACCs original decision was upheld this means the decision remains in force.
2. Quashed: ACCs original decision was overturned or ACC were required to investigate further and make
a fresh cover decision, in accordance with directions the reviewer gave.
3. Withdrawn/settled: The review application was withdrawn by the client or ACC settled the review prior
to proceeding to a hearing.

Prior to the review outcome; of the 810 surgical mesh-related claims, 628 claims (78%) had accepted decisions
and 182 (22%) had declined decisions. After the review outcome; 640 claims (79%) had accepted decisions and
170 (21%) had declined decisions.

Of the 810 surgical mesh-related claims, 35 claims had a review outcome.

Of the 35 reviews, 18 (51%) proceeded to a hearing. Of the 18:

13 were dismissed with a median timeframe of 328 days from review lodgement to review outcome.
5 were quashed with a median timeframe of 124 days from review lodgement to review outcome.

Of the 35 reviews, 17 (49%) did not proceed to a hearing and were withdrawn/settled. The median timeframe
was 39 days from review lodgement to review outcome. A review application may be withdrawn by the client
prior to proceeding with the review, or ACC agreed to reinvestigate the decision upon receiving new information
or the original decision was amended before proceeding to a hearing.

Please note that the data only relates to reviews on treatment injury claim cover decisions and excludes reviews
for ACCs other decisions, such as entitlements.

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Table 2 Number of surgical mesh-related claims for POP and/or SUI repair with a review outcome

Surgical mesh-related claim counts for POP and/or SUI repair

by review outcome from 1 July 2005 to 30 June 2017
Review outcome n %
Dismissed 8 35%
Quashed <4 -%
Withdrawn/settled 13 57%
Note: Claim counts fewer than four (n=1, 2 or 3) are presented as <4; percentages are not provided for <4 value.

Table 2 shows the surgical mesh-related claims for POP and/or SUI repair that went to review and have a review
outcome.

ACC data has identified three main review outcomes on treatment injury decision, these are:

1. Dismissed: ACCs original decision was upheld this means the decision remains in force.
2. Quashed: ACCs original decision was overturned or ACC were required to investigate further and make
a fresh cover decision, in accordance with directions the reviewer gave.
3. Withdrawn/settled: The review application was withdrawn by the client or ACC settled the review prior
to proceeding to a hearing.

Of the 470 surgical mesh-related claims for POP and/or SUI repair, less than 25 claims had a review outcome

Of these reviews:

8 were dismissed with a median timeframe of 258 days from review lodgement to review outcome
Less than four reviews were quashed with a median timeframe of 215 days from review lodgement to
review outcome.
13 reviews did not proceed to a hearing and were withdrawn/settled. The median timeframe was 35
days from review lodgement to review outcome. A review application may be withdrawn by the client
prior to proceeding with the review, or ACC agreed to reinvestigate the decision upon receiving new
information or the original decision was amended before proceeding to a hearing.

Please note that the data only relates to reviews on treatment injury claim cover decisions and excludes reviews
for ACCs other decisions, such as entitlements.

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Table 3 Number of surgical mesh-related claims for hernia repair with a review outcome

Surgical mesh-related claim counts for hernia repair by review outcome

from 1 July 2005 to 30 June 2017

Review outcome n %
Dismissed 4 40%
Quashed <4 -%
Withdrawn/settled <4 -%
Note: Claim counts fewer than four (n=1, 2 or 3) are presented as <4; percentages are not provided for <4 value.

Table 3 shows the surgical mesh-related claims for hernia repair that went to review and have a review
outcome.

ACC data has identified three main review outcomes on treatment injury decision, these are:

1. Dismissed: ACCs original decision was upheld this means the decision remains in force.
2. Quashed: ACCs original decision was overturned or ACC were required to investigate further and make
a fresh cover decision, in accordance with directions the reviewer gave.
3. Withdrawn/settled: The review application was withdrawn by the client or ACC settled the review prior
to proceeding to a hearing.

Of the 290 surgical mesh-related claims for hernia repair, less than 12 claims had a review outcome.

Of these reviews:

4 were dismissed with a median timeframe of 515 days from review lodgement to review outcome.
Less than 4 reviews were quashed with a median timeframe of 124 days from review lodgement to
review outcome.
Less than 4 reviews did not proceed to a hearing and were withdrawn/settled. The median timeframe
was 128 days from review lodgement to review outcome. A review application may be withdrawn by the
client prior to proceeding with the review, or ACC agreed to reinvestigate the decision upon receiving
new information or the original decision was amended before proceeding to a hearing.

Please note that the data only relates to reviews on treatment injury claim cover decisions and excludes reviews
for ACCs other decisions, such as entitlements.

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