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 which are included have a strict set of criteria to ensure only applicable procedures qualify for a rebate.

How Much Will Medicare Pay Towards My Cosmetic Surgery?

Medicare will not cover the entire cost of a procedure. Instead, Medicare covers 75% of the fees outlined in the Medicare Benefits Schedule. These fees are commonly significantly lower than the costs of the procedure.

Benefits of Receiving a Medicare Rebate

Your Private Health Insurance is required to assist with the cost of medical services that fall under the guidelines of the Medicare Benefits Schedule (the MBS). This typically requires a comprehensive or “top cover” policy.

If you attract a Medicare code for plastic surgery, you may be covered for private patient hospital cover, general cover (commonly known as extras), or combined hospital and general cover.

The biggest benefit of this is the reduction in the total out of pocket costs for your medically necessary plastic surgery procedure.

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).

According to Pulsus Medical Research Journal, the four factors that drive people towards having cosmetic surgery include body dissatisfaction, physical appearance, teasing and media influence – with body dissatisfaction ranking the highest. Being dissatisfied with your body and seeking to change it through surgery typically identifies as a cosmetic reason. Breast augmentation, liposuction and facelift are popular examples of cosmetic surgery procedures.

If the dissatisfaction stems from disfigurement, injury, trauma or illness, and surgery is required to correct the issue, then the surgery is likely to be medically indicated. Conditions which impact your quality of life are the ones which are most likely to receive a Medicare rebate. So corrective procedures such as reconstructive surgery, belt lipectomy following weight loss and breast reduction to correct large and heavy breasts are likely to attract a Medicare rebate.

Valid medical reasons for undergoing plastic surgery include:

  • Rhinoplasty to rectify an obstructed nasal 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.

Why Choose Dr Doyle to Claim Medicare Funding

Plastic surgeons and cosmetic surgeons are not the same. Plastic surgeons undergo longer and more extensive surgical training, and this makes a big difference when it comes to Medicare. Medicare and your Health Fund will only cover you if you approach a fully-trained and qualified accredited plastic surgeon, rather than a cosmetic doctor.

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. His most commonly used item numbers for Breast, Body, Face and Nose surgery include:

Breast Surgery Medicare Item Numbers

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 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)

Will Medicare Cover My Breast Reduction Surgery?

There is significant research that indicates women’s heavy, sagging & droopy breasts 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 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) without surgical repositioning of the nipple:

(a) excluding the treatment of gynaecomastia; and

(b) not with 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 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.

  • 45553

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 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 Breast Lift Surgery?

Medicare may contribute to your breast lift surgery if you are suffering from rashes and chronic skin infections, your breasts are sagging significantly (where at least two-thirds of the breast tissue is below the breast crease), or have another breast-related health condition which impacts your quality of 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

(b) if the patient has been pregnant—the correction is performed not less than 1 year, or more than 7 years, after completion of the most recent pregnancy of the patient; 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 sagging required to meet the item number description is very uncommon.

Body Surgery Medicare Item Numbers

Will Medicare Cover My Body Contouring Surgery After Massive Weight Loss?

In order to qualify for a Medicare rebate for body contouring 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) which 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:

  • 30165 

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:

  • 30171

Lipectomy, wedge excision of redundant non abdominal skin and fat that is a direct consequence of significant weight loss, not being a service associated with a service to which item 30165, 30168, 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 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; and

(d) the procedure involves 2 excisions only

for Tummy Tuck surgery:

  • 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 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

Face Surgery Medicare Item Numbers

Will Medicare Cover My Blepharoplasty Eyelid Surgery?

Eyelid surgery may attract Medicare benefits and private health fund cover 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 is the surgery is performed to reconstruct eyelid cancer defects, 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:

(a) the reduction is for any of the following:

(i) skin redundancy that causes a visual field defect (confirmed by an optometrist or ophthalmologist) or intertriginous inflammation of the eyelid;

(ii) herniation of orbital fat in exophthalmos;

(iii) facial nerve palsy;

(iv) post-traumatic scarring;

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

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient 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 congenial birth defects. The following item numbers apply:

for Septoplasty:

  • 41671

NASAL SEPTUM, SEPTOPLASTY, SUBMUCOUS RESECTION or closure of septal perforation

  • 41672 

Reconstruction of the nasal septum

for Rhinoplasty:

  • 45635

Rhinoplasty, partial, involving correction of bony vault only, 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

  • 45641

Rhinoplasty, total, including correction of all bony and cartilaginous elements of the external nose, with or without autogenous cartilage or bone graft from a local site (nasal), 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

Further Reading on Medicare Coverage of Plastic Surgery

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

About Dr Mark Doyle FRACS (Plast) – Queensland Plastic Surgeon

Servicing patients in Gold Coast, Brisbane, Sunshine Coast, Cairns and New South Wales NSW – Northern Rivers, Byron Bay, Ballina, Lismore and more.

Dr Mark Doyle is a Specialist Plastic Surgeon with over thirty years of experience performing BreastBodyFace and Nose surgery. As a highly esteemed plastic surgeon, Dr Mark is driven by an intense passion for helping patients achieve a happier, more beautiful self through advanced cosmetic surgery procedures.

He maintains a strong commitment to achieving the best possible results for all his breast, body, face and nose patients, both men and women.

NEXT STEPS

Do Your Research

What to Bring to Your Plastic Surgeon Consultation

  • Bring a friend or relative for support and discussion regarding your choices
  • Take notes and read all provided information thoroughly
  • Read about what to expect in your Initial Surgery Consultation

Book Your Plastic Surgery Consultation

  • Get a Referral from your GP or specialist – this is advised but not required to book a consultation with Dr Doyle.
  • Email us or call on 07 5598 0988 to arrange your consultation appointment.
  • Pay your $285 Consultation Fee in advance to secure your consultation.

Please contact us to arrange to book a consultation with our Specialist Plastic Surgeon or to speak with our Patient Care Advisor.

Send an enquiry form today or phone 07 5598 0988 during Clinic Hours.


*DISCLAIMER: All information on Gold Coast Plastic Surgery website is general in nature and is not intended to be medical advice nor does it constitute a doctor-patient relationship. Results can vary significantly and depend on individual patient circumstances. All images on this website, unless specified as real patient images, are stock images used for illustrative purposes only. Surgery risks and complications will be covered in detail during a consultation with your surgeon. Book a consult for details regarding your cosmetic surgery procedure.