What Plastic Surgery is Covered by Medicare?

Will Medicare cover my surgery? Does my private insurance cover my surgery? These are questions often asked of us, and the answer is: it essentially depends on the surgical procedure you are having.

Medicare is the Commonwealth government of Australia’s universal health scheme. It covers plastic surgery procedures if they are classified as medically necessary as opposed to purely cosmetic in nature. If a procedure is deemed medically necessary, there will be a Medicare Item Number assigned to it. These Item Numbers are listed in the Medicare Benefits Schedule (see www.mbsonline.gov.au for more info). If there is an item number, there will be some kind of rebate, and possibly an ‘out of pocket’ costs also.

To claim a Medicare rebate, you will need a referral from your GP to a Specialist Plastic and Reconstructive Surgeon who will ascertain whether or not your procedure qualifies as medically necessary. Medicare does not pay for hospital admission into a private hospital as this is considered one of your ‘out of pocket’ expenses, although your Private Health Insurance might cover this cost if a Medicare item number applies to your surgery and you have the appropriate level of cover.

Some of the procedures that qualify for a Medicare rebate include the following:

BREAST SURGERY - Breast reductions are considered a medical rather than a cosmetic procedure due to the significant symptoms often experienced by women with large breasts, which can include neck and back pain, and chronic skin irritation. Breast lifts are eligible for a Medicare rebate in some cases, such as when a reduction in breast tissue is required (e.g., to address breast asymmetry). Breast implant replacement is only eligible for a Medicare rebate if the replacement is necessary due to a complication related to the implant such as implant rupture or migration. There is no Medicare rebate for cosmetic breast augmentation. Male breast reduction or gynaecomastia surgery is considered a reconstructive procedure and 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.

OTHER TYPES OF SURGERY - A rhinoplasty or ‘nose job’ qualifies for a Medicare rebate if the surgery is being performed to correct nasal obstruction or a developmental or post-traumatic deformity. Upper eyelid reduction or blepharoplasty is eligible for a Medicare rebate if the upper eyelid skin touches the eyelashes when looking straight ahead thereby obstructing the visual field. Other reasons for the surgery that will attract a Medicare rebate include: addressing an accidental injury, birth deformities, and reconstruction after cancer. An arm lift or brachioplasty is only covered by Medicare if the person is experiencing significant symptoms such as rashes and skin ulceration or if the excess skin is significantly interfering with daily living, and weight loss has been substantial and sustained for at least six months. Otoplasty or the surgical pinning back of ears is considered a medical procedure and is therefore covered in part by Medicare.

TUMMY-TUCK SURGERY - A Medicare rebate is also available for people undergoing a ‘tummy tuck’ or abdominoplasty if there has been significant weight loss which has remained stable for at least six months and you are suffering from negative symptoms arising from the excess skin left over from their weight loss. These symptoms can include pain and skin irritation, which has not responded to treatments such as barrier creams. The excess skin you have will also need to significantly interfere with your daily life in order for you to qualify for a Medicare rebate for abdominoplasty surgery.

The criteria for Medicare rebates for Plastic and Reconstructive Surgery means that not all people will for a rebate. Those who do not qualify for a rebate might still benefit from the procedure. The best way to determine what your procedure will cost (with or without a Medicare rebate and Private Health Insurance) is to have a consultation with a Specialist Plastic and Reconstructive Surgeon who will spend time talking with you about your concerns and determine with you the most appropriate surgery, including all of the risks and benefits, and costs involved.