Will Medicare Cover Me?

Medicare Codes – Plastic Surgery Definitions, Criteria and Rebates

The Medicare Benefits Schedule (MBS) refers to a list of the medical services for which the Australian Government will provide a Medicare rebate to assist patients financially with the costs of their medical services. It determines the set rebate amounts that the Australian government will pay for medical services or procedures and are identified through ‘item numbers.’ This schedule does not include all medical procedures, and the procedures that are included have a strict set of criteria to ensure only applicable procedures qualify for a rebate.

Medicare and Breast, Body, Face and Nose Surgery – Cosmetic vs Medical Reasons

It’s important to be aware that plastic surgery only qualifies for a Medicare rebate when it is performed out of medical necessity (for health indications and not cosmetic reasons).

Valid medical reasons for undergoing plastic surgery include:

• Rhinoplasty to rectify an obstructed nasal breathing passage
• Breast reconstruction following a mastectomy or removal/replacement of breast implant/s
• Surgery following massive weight loss (removal of loose skin)

With other procedures, it’s important to consult with Dr Doyle to determine if you will be covered.

Dr Mark Doyle has over 30 years of experience working with Medicare Item Numbers. He is able to carefully and stringently identify conditions that meet the strict guidelines set by Medicare.

Breast Surgery Medicare Item Numbers

Will Medicare Cover My Breast Lift Surgery?

Medicare may contribute to your breast lift surgery if you are suffering from rashes and chronic skin infections, your breasts have significant excess skin (where at least two-thirds of the breast tissue is below the breast crease), or have another breast-related health condition that impacts your everyday life. The following Medicare item numbers apply:

• 45558

Breast ptosis, correction by mastopexy of (bilateral), if:

(a) at least two-thirds of the breast tissue, including the nipple, lies inferior to the infra-mammary fold where the nipple is located at the most dependent, inferior part of the breast contour; and

(c) photographic evidence (including anterior, left lateral and right lateral views), with a marker at the level of the inframammary fold, demonstrating the clinical need for this service, is documented in the patient notes

Applicable only once per lifetime

• 45556

Breast ptosis, correction of (unilateral), in the context of breast cancer or developmental abnormality, if photographic evidence (including anterior, left lateral and right lateral views) and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

Applicable only once per occasion on which the service is provided.

Note: This item number is rarely used because the degree of ptosis required to meet the item number description is very uncommon.

Will Medicare Cover My Breast Reduction Surgery?

There is significant research that indicates women’s heavy breasts with excess fat and excess skin can cause neck pain, shoulder pain, rashes or infections and that these health concerns can be greatly relieved by breast reduction surgery (Reduction Mammoplasty). The following MBS codes may apply:

• 45520

Reduction mammaplasty (unilateral) with surgical repositioning of nipple, in the context of breast cancer or developmental abnormality of the breast

• 45522

Reduction mammaplasty (unilateral) with surgical repositioning of nipple, in the context of breast cancer or developmental abnormality of the breast

(a) excluding the treatment of gynaecomastia; and
(b) not with the insertion of any prosthesis;

• 45523

Reduction mammaplasty (bilateral) with surgical repositioning of the nipple:

(a) for patients with macromastia and experiencing pain in the neck or shoulder region; and

(b) not with the insertion of any prosthesis

Will Medicare Cover My Breast Implant Removal Surgery?

Breast implant removal surgery may attract a Medicare rebate if the surgery is indicated because of issues with the breast implant, disease of or trauma to the breast (other than trauma resulting from previous elective surgery), there is an infection or it prevents treatment for breast cancer. The following item numbers apply for breast implant removal surgery:

• 45551

Breast prosthesis, removal of, with excision of at least half of the fibrous capsule, not with insertion of any prosthesis. The excised specimen must be sent for histopathology and the volume removed must be documented in the histopathology report.

• 45548

BREAST PROSTHESIS, removal of, as an independent procedure

• 45552

Breast prosthesis, removal of and replacement with another prosthesis, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture), if:

(a) either:

(i) It is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity; or

(ii) the original implant was inserted in the context of breast cancer or developmental abnormality; and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient’s notes

• 45554

Breast prosthesis, removal and replacement with another prosthesis, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture), including excision of at least half of the fibrous capsule or formation of a new pocket, or both, if:

(a) either:

(i) It is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity; or

(ii) the original implant was inserted in the context of breast cancer or developmental abnormality; and

(b) the excised specimen is sent for histopathology and the volume removed is documented in the histopathology report; and

(c) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes.

Will Medicare Cover My Gynaecomastia Surgery?

Male breast reduction or gynaecomastia surgery is considered a reconstructive procedure. It is therefore medical in nature, making it potentially eligible for a Medicare rebate. Surgical excision of breast tissue and/or liposuction can be used, and either technique may include a Medicare rebate. The following item code applies:

• 31525

BREAST, mastectomy for gynecomastia, with or without liposuction (suction assisted lipolysis), not being a service associated with a service to which item 45585 applies (H)

Body Surgery Medicare Item Numbers

Will Medicare Cover My Body Surgery After Massive Weight Loss?

In order to qualify for a Medicare rebate for body surgery after massive weight loss, you need to have lost at a minimum, 5 BMI points – typically 15kg or more for an average person. You’ll need to have maintained this weight loss by keeping at a stable weight for at least 6 months. You must suffer skin conditions (rashes or chaffing) that have been treated using non-surgical methods for 3 months with minimal improvement. And, you need to be able to prove that this excess skin following weight loss interferes with your daily activities including exercise. The following item numbers apply…

for Body Lift Surgery:

• 30166

Lipectomy, wedge excision of abdominal apron that is a direct consequence of significant weight loss, not being a service associated with a service to which item 30168, 30171, 30172, 30176, 30177, 30179, 45530, 45564 or 45565 applies, if:

(a) there is intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non-surgical) treatment; and

(b) the abdominal apron interferes with the activities of daily living; and

(c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy

for Arm Lift and Thigh Lift surgery:

• 30169

Removal of redundant non-abdominal skin and lipectomy for functional problems following significant weight loss equivalent to at least 5 body mass index points and if there has been a stable weight for a period of at least 6 months prior to surgery, one or 2 non-abdominal areas, other than a service associated with a service to which item 30175, 30176, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies.

for Tummy Tuck surgery (Abdominoplasty):

• 30177

Lipectomy, excision of skin and subcutaneous tissue associated with redundant abdominal skin and fat that is a direct consequence of significant weight loss, in conjunction with a radical abdominoplasty (Pitanguy type or similar), with or without repair of musculoaponeurotic layer and transposition of the umbilicus, not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30176, 30179, 45530, 45564 or 45565 applies, if:

(a) there is intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non-surgical) treatment; and

(b) the redundant skin and fat interferes with the activities of daily living; and

(c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy

From July 1, 2022, item number 30175 for Tummy Tuck surgery (Abdominoplasty) will be accessible on the MBS.

The criteria will be as follows (this is correct at the time of writing in May 2022, but is subject to change in accordance with the MBS):

Radical abdominoplasty, with repair of rectus diastasis, excision of skin and
subcutaneous tissue, and transposition of the umbilicus, not being a laparoscopic
procedure, where the patient has an abdominal wall defect as a consequence of
pregnancy, if:

(a) the patient has an abdominal wall defect as a consequence of pregnancy; and
(b) the patient:

(i) has a diastasis of at least 3cm measured by diagnostic imaging prior to this service; and
(ii) has either or both of the following:

(A) at least moderately severe pain or discomfort at the site of the diastasis in the abdominal wall during functional use and the pain or discomfort has been documented in the patient’s records by the practitioner providing the service;
(B) low back pain or urinary symptoms likely due to rectus diastasis and the pain or symptoms have been documented in the patient’s records by the practitioner providing the service; and

(iii) has failed to respond to non-surgical conservative treatment, that must have included physiotherapy; and
(iv) has not been pregnant in the last 12 months; and

(c) the service is not a service associated with a service to which item 30166, 30169, 30176, 30177, 30179, 30651, 30655, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies

Face Surgery Medicare Item Numbers

Will Medicare Cover My Blepharoplasty Eyelid Surgery?

Eyelid surgery may attract Medicare benefits and private health fund coverage if your vision is impaired due to excess skin resting on your eyelashes or due to a weak or droopy eyelid (Eyelid Ptosis). It may also attract a Medicare rebate if the surgery is performed to reconstruct eyelid cancer defects, and improve accidental injuries, birth deformities and eyelid malposition such as entropion and ectropion. The following MBS item numbers apply:

• 45617

Upper eyelid, reduction of, if:

(i) history of a demonstrated visual impairment;

(ii) intertriginous inflammation of the eyelid;

(iii) herniation of orbital fat in exophthalmos;

(iv) facial nerve palsy;

(v) post‑traumatic scarring;

(vi) the restoration of symmetry of the contralateral upper eyelid in respect of one of the conditions mentioned in subparagraphs (i) to (v); and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient’s notes

Note: the rebate for upper eyelid reduction surgery is very low and not dissimilar to the cost of having the necessary ophthalmological investigations.

Will Medicare Cover My Otoplasty Surgery?

Otoplasty or the surgical pinning back of ears is considered a medical procedure and is therefore covered in part by Medicare. To claim this rebate, the surgery must be performed before the age of 18. After the age of 18, it is considered an elective cosmetic surgery procedure. The following item number applies:

• 45659

Correction of a congenital deformity of the ear if:

(a) the patient is less than 18 years of age; and

(b) the deformity is characterised by an absence of the antihelical fold and/or large scapha and/or large concha; and

(c) photographic evidence demonstrating the clinical need for this service is documented in the patient notes

Nose Surgery Medicare Item Numbers

Will Medicare Cover My Nose Surgery?

Medicare may cover Septoplasty or Rhinoplasty in part if breathing difficulty or septum problems exist due to trauma to the nose, a previous Rhinoplasty procedure or congenital birth defects. The following item numbers apply:

for Septoplasty:

• 41671

Septal surgery, including septoplasty, septal reconstruction, septectomy, closure of septal perforation or other modifications of the septum, not including cauterisation, by any approach, other than a service associated with a service to which item 41689, 41692 or 41693 applies

for Rhinoplasty:

• 45632

Rhinoplasty, partial, involving correction of one or both lateral cartilages, one or both alar cartilages or one or both lateral cartilages and alar cartilages, if:

(a) the indication for surgery is:

(i) airway obstruction and the patient has a self-reported nose scale score of greater than 45; or

(ii) significant acquired, congenital or developmental deformity; and

(b) photographic and/or NOSE Scale evidence demonstrating the clinical need for this service is documented in the patient’s notes

• 45644

Rhinoplasty, total, including correction of all bony and cartilaginous elements of the external nose involving autogenous bone or cartilage graft obtained from distant donor site, including obtaining of graft, if:

(a) the indication for surgery is:

(i) airway obstruction and the patient has a self‑reported NOSE Scale score of greater than 45; or

(ii) significant acquired, congenital or developmental deformity; and

(b) photographic and/or NOSE Scale evidence demonstrating the clinical need for this service is documented in the patient notes;

other than a service associated with a service to which item 45718 applies (H)

Further Reading on Medicare Coverage of Plastic Surgery

• Will Medicare Cover My Breast Implant Removal in Queensland?
• Will Medicare Cover My Abdominoplasty in Queensland?
• Will Medicare Cover My Breast Lift in Queensland?
• Will Medicare Cover My Rhinoplasty in Queensland?

How to Apply For a Medicare Rebate 

In Australia, all plastic surgeons who are registered with the Australian Society of Plastic Surgeons (ASPS) are recognised by Medicare. This gives them the authority to determine your eligibility for an MBS item number rebate. To receive a Medicare rebate for a medically indicated procedure, first, you must ensure that your procedure is listed on the MBS and you have a valid referral from a GP to attend your specialist. Then, during your initial consultation, you will discuss your concerns with Dr Doyle and based on his understanding of the MBS, he will decide if you qualify for Medicare funding. If this is the case, evidence – surveys and photos (before, during and after surgery) – will be collected and stored on your file. If Medicare raises any concerns regarding your rebate, the Doyle team will provide this evidence as part of your claim.

Medical References

• Factors that motivate people to undergo cosmetic surgery – Pulsus
• Search the MBS – MBS Online