Will Medicare cover my Plastic Surgery?

Can I claim my Plastic Surgery on Medicare?

What is Medicare?

Medicare is an Australian Government funded program giving Australians the right to be provided with medical health care based on medical need. Some procedures in plastic surgery are required on a ‘medical needs’ basis and these can include body contouring surgery after significant weight loss and reconstruction of facial deformity, such as post-traumatic rhinoplasty. When patients approach a plastic surgeon regarding a procedure, the surgeon will decide if this procedure is medically necessary and should be covered by Medicare or whether it is purely cosmetic and not covered.

NEW ITEM NUMBER UPDATE – The Australian Government has a NEW Medicare Item Number for a Tummy Tuck for some eligible post-pregnancy patients with 3cm+ Diastasis Recti (Split Tummy Muscles) if you are eligible and meet the new medical criteria. This new 30175 Medicare Item Number – is effective from 1st July 2022. Read the 30175 Medicare Item Number factsheet.

If you qualify for the 30175 Medicare item number you may also get a subsidy from your Health Fund. There will still be a significant out-of-pocket GAP as Private Tummy tuck surgery is NOT FREE.

You can visit the Medicare MBS ONLINE website to find out the detailed criteria for any Medicare Item Numbers you wish to use.

What is a Medicare Item Number?

If the procedure is medically needed, then it is possible that it will attract a Medicare item number. The Medicare item number is the coding system used by Medicare to describe particular medically necessary procedures. This number is then used by private health funds to determine whether hospital and operating theatre costs will be covered by the health fund, as well as determining the rebates for anaesthetic and surgical services.

If a procedure does not attract or fulfill the criteria of the Medicare item number, then the procedure is deemed to be one hundred percent elective or cosmetic which means all costs related to that procedure, including hospital costs, operating theatre costs, surgeon and anaesthetic costs would need to be paid by the patient. The decision as to whether a Medicare item number is necessary for a particular patient needs to be assessed at the time of consultation with your surgeon.

How do you qualify for a Medicare Item Number?

A Patient consultation allows the surgeon to determine the medical need and whether a Medicare item number criteria are met and the procedure is necessary. If a Medicare item number is necessary, it can only be used if the patient has a valid referral from a medical practitioner or specialist.

This is why it is important for patients who are seeking treatment of potentially medically related conditions, such as post weight loss surgery, breast reduction or lift  or a post-trauma correction, to have a referral from a general practitioner. This referral chain ensures that the Medicare system is appropriately used and that all the criteria are satisfied to ensure that the procedure is a medical need and is not an elective procedure.

You’ll need a valid Medical Referral 

If a Medicare item number is applicable to  a particular procedure, it can only be used if the patient has been referred to their surgeon by a medical practitioner. Therefore, it is important for patients who seek treatment to have a referral from their doctor or specialist if they hope to claim a Medicare rebate or a Private Health Fund claim.

Dr Hunt’s Advice to Patients about a Medical Referral

Dr Hunt advises his patients that a medical referral from a GP will mean they will have a rebate from Medicare for a portion of the initial consultation fee. Once this referral has been put in place from a general practitioner, any subsequent medical treatments that do attract a Medicare item number would be deemed to be medical in nature.

This is why you will find that many practitioners will request patients obtain a referral prior to seeking treatment so that, in the event that ongoing surgical treatment is implemented on medical grounds, it is done so in a valid and appropriate manner with the appropriate foundation in place at the first instance, being a referral from a general practitioner to the surgeon

What popular plastic surgery procedures are covered by Medicare?

Medicare for Breast Reduction – Item Number 45523

A breast reduction due to disproportionately large breasts that cause excessive physical discomfort such as back, neck and shoulder pain may be deemed a medically necessary procedure. To be eligible for a Medicare breast reduction, you will need to be assessed by a Plastic Surgeon. Although Medicare may recognise the need for the procedure on medical grounds and you may fill the criteria for a breast reduction under Medicare, few Plastic Surgeons have the option of performing the surgery in a Public Hospital.

Medicare for Nose Surgery – (see six Item Numbers below)

When nose surgery is required due to a medical issue such as an obstruction to the nasal airway, the procedure may meet the Medicare criteria as the surgery is needed to improve nasal breathing. If there is a medical issue such as a post-traumatic deformity to the nose, Medicare may also recognise the medical need to perform a rhinoplasty. As these examples are recognised as necessary medical procedures, a Medicare rebate will be associated with them.

Medicare for Tummy Tuck – Item Number 30177

Medicare will not cover a tummy tuck purely for cosmetic reasons, but in situations where a patient has achieved significant weight loss, this may classify as an essential procedure and be eligible for a Medicare rebate. The weight loss has to be of 5 BMI points or more and has to have been maintained for a period of at least six months. The level of excess skin remaining has to be proven to be interfering with daily life (causing skin rashes), and non-surgical treatments have been attempted and have failed.

Other Medicare Item Numbers

There are many other Medicare Item Numbers for other plastic surgery like  Excess Skin Removal, Arm lift, Thigh Lift, Labiaplasty, Nose Surgery for Breathing problems. (see below)

Medicare Item Numbers mostly used by Specialist Plastic Surgeons include

BREAST SURGERY MEDICARE ITEM NUMBERS

  • Breast Lift For Sagging or Ptotic Breasts – 45558
  • Breast Reduction – 45523
  • Breast Asymmetry – 45524
  • Tuberous Breasts Correction – 45060
  • Breast Implant Removal – Capsulectomy 45551
  • Gynecomastia – Male Breast Reduction 31525
  • Fat Transfer For Breast Reconstruction (New Codes Nov 2021)

BODY SURGERY MEDICARE ITEM NUMBERS

Most of these surgeries are specifically for excess skin reduction after massive weight loss

  • Abdominoplasty – Tummy Tuck for Excess Skin Removal after Weight Loss  – 30165, 30177 Or 30171
  • Abdominoplasty for Diastasis Recti Repair after Pregnancy – 30175 (New Item from 1st July 2022)
  • Brachioplasty – Arm Lift 30171
  • Lower Body Lift – Belt Lipectomy 30179
  • Thigh Lift – 30171
  • Upper Body Lift – 45523 + 30171
  • Hernia Repair – 30621
  • Labiaplasty – 35534 35533 (Strict criteria apply)

FACIAL SURGERY MEDICARE ITEM NUMBERS

  • Blepharoplasty – Eyelid Surgery – 45617
  • Browlift / Forehead Surgery – 42872, 40600, 39330, 41746
  • Genioplasty – Chin Surgery 45761
  • Otoplasty – Ear Correction Under 18 only – 45659
  • Nose Surgery – Rhinoplasty, Septoplasty, Turbinectomy –  41671, 41672, 45641, 45644, 41689, 45635
  • Fat Grafting To Face (Revision)  – 45506 If Revision

SKIN & MINOR SURGERY MEDICARE ITEM NUMBERS

  • Skin Lesions – Flaps Or Grafts 45201 45445 and Many Other Item Numbers
  • Removal Of A Foreign Body 30068
  • Scar Revision – 45515 – Other Than Neck/Face 45506 Face/Neck
  • Removal Of Threads 30068
  • Kenacort 30207 (Keloid Scar Treatment)
  • Biopsy 30071

There are many other Medicare item numbers – please visit the MBS website for more detail

What Cosmetic Surgery is UNLIKELY to be covered by Medicare?

It is highly unlikely that your plastic surgeon will use a medicare item number for any purely cosmetic procedure (other than for cancer or trauma reconstruction).

So the following procedures are unlikely to be covered by Medicare…

  • Facelift or Neck Lift (other than reconstruction)
  • Cheek Implants
  • Liposuction or Liposculpture
  • Fat Transfer To Breasts For purely Cosmetic Reasons
  • Buccal Fat Removal or Cheek Reduction
  • Earlobe Reduction or Repair
  • Tracheal Shave (Adam’s Apple Surgery)

Does BUPA or other Private Health Insurance cover my surgery?

Private health insurance also has very strict guidelines about plastic surgery procedures they are willing to cover. If your plastic surgery procedure does qualify for a Medicare rebate, your private health insurance MAY also cover some of the costs of the anaesthetist fee, hospital fee, and post-surgical garments. Of course, health fund policies vary greatly, as does the level of cover they offer. It’s essential to understand your policy and all the restrictions and requirements. To find out more please phone your health fund and quote the item number you qualify for.

What is Gap and No-Gap Surgery?

Medicare was created to ensure that all Australians have access to essential health care. It is a system of categorisation for medically necessary procedures where the government covers the costs. The Medicare Schedule of Fees was written some time ago, and it has failed to keep pace with the cost of providing medical care. This then creates what is known as “the gap” – the difference between what Medicare pays the surgeon for performing the procedure, and what the surgeon may charge for the procedure. In a modern private plastic surgery practice, the medicare rebate is small compared to the costs of running the practice and providing high levels of service, hence there is a large ‘out of pocket’ expense.

About Dr Jeremy Hunt – Plastic Surgeon

dr jeremy hunt - is gynecomastia surgery covered by medicare

Dr Jeremy Hunt is one of Australia’s leading specialist plastic surgeons for breastbodyface and nose surgery.

He is a member of FRACS & ASPS and has over 20 years of experience providing expert cosmetic and plastic surgery in Sydney.

Careful, considerate and honest, Dr Jeremy Hunt works with you to find a solution that is best for your body and your lifestyle. Every patient is unique and, through his expert guidance,

Dr Hunt’s personal, one-on-one service and attention to detail has given thousands of women and men from the Sydney & Wollongong NSW area and across Australia the confidence and body shape they desire.

Dr Hunt’s qualifications and education

Dr Jeremy A Hunt MBBS FRACS graduated with a Bachelor of Medicine degree from Sydney University in 1990 and is a Fellow of the Royal Australasian College of Surgeons and member of the Australian Society of Plastic Surgery. He completed a Fellowship at the prestigious University of Texas in the United States, where he learnt from some of the world’s very best plastic surgeons.

Next Step – Make an Enquiry or Request a consultation with Dr Hunt

Want more information before scheduling your consultation?

If plastic surgery is something you’re considering, Dr Hunt can thoroughly explain all the options to you in a one-on-one consultation.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health professional.