Can I claim my Ear Correction Surgery on Medicare?
Ear Correction surgery or Otoplasty is a popular procedure for patients who want to reduce their overly prominent ears. We often receive inquiries about what criteria need to be met for Medicare and private health insurance to fund the procedure. In this article, we will try to explain who can apply for a partial refund from Medicare for ear correction surgery.
Will Private Health Insurance (PHI) cover Ear Surgery?
In order to apply for financing using your private insurance, you must be eligible for the Medicare item number. However, if you are a user of private health insurance, we recommend that you communicate directly with them to get more information about the conditions you must meet.
Furthermore, in certain cases, it is possible to apply for Early Release of Super Funds to pay for your Ear surgery. However, this process also requires compliance with certain government rules and does not guarantee a fund release. Especially in cases where the surgery is requested for purely aesthetic reasons.
Popular Reasons for Wanting to Have Ear Surgery
Protruding ear correction is one of the most common cosmetic and corrective surgical procedures. Ear deformity in terms of distance from the head is the most common hereditary anomaly among numerous other deformities on the outer part of the ear, and is often noticeable immediately after birth. However, the growth and development of the ear does not normally end until the fourth year, it is at this point, that the severity of the “detachment” can be determined.
Many parents and patients decide to have this procedure done at a young age.
The characteristics of such ears include:
- Ears with large folds and pronounced cartilage
- “Stretched” or amorphous ears
- Asymmetrical ears
- Ears too distanced from the head
Ear surgery, in terms of otoplasty, does not affect hearing and as a result, is entirely aesthetic in nature.
How do I Qualify for the Medicare Rebate?
Medicare, as well as private health insurers, require that certain conditions and requirements be met in order to fully or partially fund ear surgery. The Medicare Benefits Schedule (MBS) contains a numbered categorization of all interventions, which contains all the conditions required for rebates.
Ear Surgery, medically known as Otoplasty, falls under the category of surgical operations, and a subgroup of Plastic and Reconstructive surgery.
The corresponding MBS code is: 45659 – Correction of a congenital deformity of the ear
Full MBS Item Number breakdown and description:
45659 – Correction of a congenital deformity of the ear if:
- the patient is less than 18 years of age; AND
- the deformity is characterised by an absence of the antihelical fold and/or large scapha and/or large concha; AND
- photographic evidence demonstrating the clinical need for this service is documented in the patient notes
Will Medicare Cover Ear Correction Surgery for medical reasons?
Usually, Medicare and private health insurance providers are clear about their rules: you cannot claim Aesthetic procedures. But if the procedure is medically justified, as may be the case with ear surgery, it is possible that Medicare will cover some of the cost for your Ear Correction Surgery. Of course, Medicare and private health insurance providers have clear and strict requirements that must be met in order for your procedure to qualify for rebates.
Research to find out if Medicare and the MBS Covers Your Ear Surgery Procedure
- You can download a complete MBS benefits scheme to find out more about the; categorization, codes, and conditions for each procedure.
- If you are looking for a specific procedure, you can use a built-in search function to browse through the categorization faster.
- If the procedure you want is not on the MBS categorization list, Medicare is not offering reimbursement for that specific surgery.
Why is Medicare for Ear Correction Surgery Confusing for Patients Seeking Surgery?
The main reason people interested in otoplasty are confused is Medicare’s general rule that disqualifies purely aesthetic/cosmetic procedures from a rebate. Ear Correction Surgery has no significant effect on hearing and only represents an aesthetic improvement. As a result, many patients are not sure if they can apply for rebates.
However, ear protrusion can have a significant negative impact on the development of children and adolescents, therefore otoplasty can in severe cases be medically justified and necessary.
Medicare Rebates are subject to change and review
MBS Item codes can change or be removed from the Medicare rebate schedule without warning.
Top Tips for Dealing with Medicare Regarding Your Claim
- Ear surgery, as a part of Plastic Reconstructive Surgery procedures, may be medically justified and necessary
- If you are a private health insurance user, the refund may be different from Medicare’s. Contact your PHI and ask for more information.
- Since MBS descriptions and classifications are subject to almost daily changes, it is important to be up to date.
- Document each part of the process.
- Know the appropriate MBS code for ear surgery, in detail.
- Learn what the terms “medically indicated” and “Statement of benefit” means.
Further Tips For Claiming Your Ear Surgery
Before you formally apply for rebates, you need to consult with a professional plastic surgeon. Emphasis on a professional plastic surgeon, not an aesthetic surgeon who performs the procedures “in office”. Make sure your surgeon has the necessary qualifications and training. Furthermore, ask for a written confirmation that will describe the reasons and motives for requesting surgery.
It’s also important to remember that;
- General Practitioner referrals are valid for 12 months
- While a specialist referral is only valid for 3 months.
When phoning Medicare and Health funds
- Use email as a means of communication.
- A written trace of communication is very important for accepting your intervention.
- When using the phone, be patient and unobtrusive, but ask for written confirmation of every conversation had.
- Take care of the medical documentation you gather through the process.
- Make copies.
Unfortunately, CocoRuby doesn’t provide assistance with Medicare or Health Fund processing. This is solely the patient’s responsibility. However, we do list the Medicare code(s) on your Quote and on your Invoice(s). So, if you are eligible for a Medicare rebate code or health fund rebate, this can help you when it comes to submitting your paperwork.
More Information about Your Procedure
- You can Download Free Procedure Guides on your chosen surgery.
- Also, our FAQs page might help you find out more about the procedure you are interested in, and other patients’ experience.
- Alternatively, you can talk to our Patient Care Team from 8 am – 6 pm Monday to Friday on 1300 599 990
- Phone 1300 264 811 or send us an enquiry form, below.
*Disclaimer: Individual results can vary significantly from patient to patient. The information we provide is general. For further information on what to expect for your preferred procedures, arrange to see one of our Specialist Plastic Surgeons for a full-history and surgical consultation. Read further information about surgical outcome variability on our Disclaimer page.
Further Reading about Ear Correction Surgery
- Find out more about Ear Surgery Melbourne by Dr Patrick Briggs