Medicare Coverage of Plastic Surgery

Will Medicare Cover My Plastic Surgery in Melbourne VIC?

Download this Guide to understand Medicare and Health Insurance for Plastic Surgery in Victoria

Have you been thinking about getting plastic surgery but are not sure about procedures and what is affordable on our Australian Medicare system? When it comes to plastic surgery, the Medicare MBS guidelines are very clear.  Medicare will not cover ‘non-therapeutic cosmetic surgery. This means Medicare will not cover elective surgeries that you choose to pursue purely cosmetic reasons – it will only cover procedures that are clinically necessary for your health or medically necessary that meet strict criteria.

What is a valid medical reason for having plastic surgery?

A valid medical reason for surgery can include things like:

• Plastic surgery following skin cancer removal
• Facial reconstructive surgery after an accident or trauma
• Rhinoplasty to rectify an obstructed nasal passage
• Breast reconstruction following a mastectomy or removal/replacement of implant
• Surgery following massive weight loss (removal of loose skin, abdominoplasty and such)

With other procedures, the best way to find out if your own individual circumstances will be covered is to consult with a medical professional to determine if you will be covered.

All Procedures on Medicare MBS

Some of the other procedures on the MBS include:

You should always check the most up to date information via Medicare or contact our team at Coco Ruby Plastic Surgery on 1300 264 811 to discuss estimated out of pocket expenses for your specific surgery.  Our team can also give you information about our payment methods, which make plastic surgery even more accessible, with or without Medicare coverage.

MBS Item Numbers for Plastic Surgeons

Surgeon Consultation MBS Item numbers

• 104 – Consultation with Specialist
• 105 – Follow-up Consultation with Specialist
• 91822 – Teleconsult long
• 91823 – Teleconsult short

Breast Surgery MBS Item Numbers

• 31519 – Mastectomy / Total Removal of Breasts
• 31525 – Mastectomy for Gynecomastia – excision of Breast Tissue (Male Breast Reduction)
• 31551 – Breast Hematoma, Seroma or Inflammation
• 31563 – Inverted Nipple Correction
• 45060 – BA/BR for Asymmetry or Tubular Correction single stage
• 45061 – BA/BR for Asymmetry or Tubular Correction – 2 stage, part 1
• 45062 – BA/BR for Asymmetry or Tubular Correction – 2 stage, part 2
• 45515 – Scar Revision to Body < 7cm scar – not face or neck (for breast surgery)
• 45518 – Scar Revision to Body > 7cm scar – not face or neck (for breast surgery)
• 45520 – Breast Reduction Surgery Unilateral (Single side)
• 45522 – Breast Reduction Surgery Unilateral (single Side) – without nipple reposition
• 45523 – Breast Reduction Surgery Bilateral (both sides)
• 45524 – BA Unilateral / Asymmetry correction > 10% (not fat transfer)
• 45528 – BA Bilateral for Developmental malformation (not fat transfer)
• 45545 – Nipple and/or Areola Reconstruction (Nipple shortening)
• 45548 – BIR Breast implant Removal
• 45551 – BIR Breast Implant Removal with Capsulectomy
• 45553 – BIRR Remove and Replace Breast Implants due to a complication
• 45554 – BIRR Remove and Replace Breast implants due to a complication – with capsulectomy or neo subpectoral pocket
• 45556 – BL Breast Ptosis Correction Unilateral
• 45558 – BL Breast Ptosis Correction Bilateral

Breast Reconstruction MBS Item Numbers

• 45546 – Nipple and/or Areola Reconstruction (after mastectomy)
• 45527 – Breast reconstruction after Cancer – BA Unilateral after Mastectomy
• 45530 – Breast Reconstruction – Myocutaneous Flap
• 45564 – Free transfer of tissue reconstruction

Body Surgery post Weight loss Skin Removal MBS Item Numbers

• 30165 – Lipectomy – Removal of Abdo Apron after Significant Weightloss (not following pregnancy)
• 30168 – Lipectomy with one excision
• 30171 – Lipectomy skin removal after weight loss – for an Arm lift or Thigh Lift (2 excisions)
• 30172 – Lipectomy skin removal after weight loss (3 excisions or more)
• 30176 – Lipectomy (Muscle Repair Included and Umbilicus)
• 30177 – Lipectomy (with/without Muscle Repair and Umbilicus) skin removal after weight loss. e.g. Tummy Tuck / Abdominoplasty
• 30179 – Circumferential lipectomy (Torsoplasty) skin removal after massive weight loss (Belt lipectomy)
• 45569 – Closure of Abdo with the reconstruction of umbilicus
• 45051 – Contour Defect Repair – Calf Augmentation / Pectoral Augmentation (Polands Syndrome)

Hernia Surgery MBS Item Numbers

• 30621 – Umbilical, epigastric or linea alba Hernia Repair
• 30648 – repair of Femoral or inguinal hernia
• 30651 – repair of ventral hernia with closure by suture without rectus muscle advancement
• 30655 – repair of ventral hernia and rectus muscles advancement

Nose Surgery MBS Item Numbers

• 41671 – Nasal Septum, Submucous Resection, Septoplasty or closure of septal perforation.
• 41672 – Nasal septum reconstruction
• 41689 – Bilateral turbinectomies
• 41716 – Antrum, intranasal operation on, or removal of foreign body
• 41737 – Frontal sinus, or ethmoidal sinuses on the one side.
• 41752 – Bilat Sphenoidotomies
• 41786 – PalatoPharyngoPlasty + Tonsillectomy, Coblator Palatoplasty
• 45632 – Rhinoplasty partial involving correction of lateral or alar cartilages
• 45635 – Rhinoplasty partial for Bony vault correction – airway obstruction
• 45641 – Rhinoplasty, for airway congestion or deformity correction
• 45644 – Rhinoplasty for an obstructed airway – using distant donor materials
• 45650 – Rhinoplasty for obstructed airway or deformity
• 45675 – Coblator Tongue Channelling

Eye and Ear Correction MBS Item Numbers

• 42590 – Canthoplasty
• 42866 – Entropian or Tarsal Ectropian
• 45617 – Reduction of Upper Eyelid
• 45620 – Reduction of Lower Eyelid
• 45623 – Correction of Ptosis of Upper Eyelid
• 45624 – Correction of Ptosis of Upper Eyelid (revision)
• 45625 – Correction of Eyelid Ptosis (revision)

Female Genital Surgery MBS Item Numbers

• 35533 – Vulvoplasty or Labiaplasty for repair of mutilation or anomaly
• 35534 – Vulvoplasty or Labiaplasty for structural abnormality

Gender Surgery MBS Item Numbers

• 31519 – Breast, Total Mastectomy (FTM Breast Removal)
• 45451 – Free Grafting (full thickness)
• 41879 – Tracheoplasty Tracheal Shave – Adam’s Apple Reduction
• Does not cover Breast Implant Surgery MTF Top Surgery

Scar Revisions and Free Grafting MBS Item Numbers

• 45506 – Scar Revision to Face
• 45512 – Scar Revision to Face
• 45515 – Scar Revision to Body < 7cm scar – not face
• 45518 – Scar Revision to Body > 7cm scar – not face or neck
• 45451 – Free Grafting Full thickness
• 45455 – Free Grafting
• 45200, 45201, 45202, 45203, 45206 – Local Skin Flap

Chin Surgery MBS Item Numbers

• 52378 – Genioplasty
• 52321 – Foreign implant

Weight Loss Surgery MBS Item Numbers

• 31575 for Sleeve Gastrectomy
• 31572 for Gastric Bypass Surgery
• 31369 for Lap Band Surgery (Item 31584 for Lap-Band Removal)

Skin lesions MBS Item Numbers

• 31356
• 31357
• 31358
• 31359
• 31360
• 31361
• 31362
• 31363
• 31364
• 31365
• 31366
• 31367
• 31368
• 31369
• 31370
• 31371
• 31372
• 31373
• 31375
• 31376

Other Surgery

• Full face chemical peel for severely sun-damaged skin or severe chloasma or melisma (also often termed the ‘mark of pregnancy’)
• Abrasive therapy for severely disfiguring scarring resulting from trauma, burns or acne
• Carbon dioxide laser or erbium laser resurfacing of the face or neck for severely disfiguring scarring resulting from burns, trauma or acne
• Gastric band surgery, where clinical morbid obesity has been diagnosed
• Cleft lip and cleft palate surgery

Visit these Coco Ruby Blogs for more information about Medicare and Private Health Insurance

Will medicare cover:

• Breast Reduction?
• Breast Lift?
• Post Pregnancy Surgery – Tummy or Breast Surgery?
• Breast Implant Revision Surgery?
• Breast Implant Removal Surgery?
• Tummy Tuck Surgery – Abdominoplasty After Weight Loss?
• Rhinoplasty – Nose Surgery?
• Eyelid Surgery – Blepharoplasty?
• Chin Surgery?
• My Labiaplasty?
• Belt lipectomy?
• Thigh Lift?
• Weight Loss Surgery – Bariatric Surgery like a Gastric Sleeve?
• Gender Affirmation/Confirmation Surgery?
• Best Tips for Dealing with Medicare when having Plastic Surgery

Who decides if I meet the Medicare criteria?

If you are embarking upon plastic surgery for a recognised medical purpose, the first step is to obtain a referral letter from your family GP to go and see a specialist.  In order to be covered by Medicare, you need to ensure that the specialist you’re referred a RACS Surgeon, preferably an accredited plastic surgeon with the Australian Society of Plastic Surgeons

Plastic Surgeons and “Cosmetic Surgeons” are NOT the same! Even though they sound similar they are different- 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 surgeon, not just a cosmetic doctor.

Is my procedure covered by Medicare?

The Medicare Benefits Schedule (MBS) is searchable online and is a great resource if you’re doing some preliminary research about your chosen procedure. Here is an overview of some of the main types of plastic surgeries that are listed on the MBS:

Will Medicare cover my Tummy Surgery?

If you meet the strict criteria, Medicare will cover an Abdominoplasty or Tummy Tuck – find out more in this blog.

Will Medicare cover my Breast Surgery?

Breast reduction mammoplasty (with or without the relocation of the nipple).  If you are a woman with fuller breasts and you are looking for a reduction because you’ve been experiencing health issues, you will be covered by Medicare.

Breast augmentation (Mammoplasty) is also on the MBS, but only under VERY LIMITED conditions:

• Where breast asymmetry exists;
• Following mastectomy; or
• Where there is a malformation of breast tissue, disease or trauma to the breast (excluding trauma from prior elective cosmetic surgery)

Breast reconstruction following mastectomy or trauma is on the list, but that again excludes any trauma caused by previous elective cosmetic surgery.  You may also be eligible for cover on Removal and/or replacement of breast prosthesis and reconstruction of the nipple or areola (or both) if there is a medical reason for the surgery.

Will Medicare Cover my Breast Lift?

Here are the criteria for MBS coverage of a Breast Lift Surgery

Will Medicare Cover My Breast Implant Surgery?

Here are the criteria for MBS coverage of Breast Implant Surgery

Will Medicare Cover My Nose Surgery or Rhinoplasty?

Rhinoplasty is on the MBS, but there are strict criteria under what circumstances it is covered.  The actual MBS goes into very specific detail about this. But if you require rhinoplasty to correct nasal obstructions or post-traumatic deformities (other than those resulting from cosmetic surgery), then you may be covered.

Will Medicare Cover My Ear Reconstruction surgery?

Ear Reconstructions are a less common procedure, reconstructive surgery of the ear is covered by Medicare to correct ‘lop ear’ or ‘bat ear’ or, other similar deformities.

Will Medicare Cover Face Surgery?

Meloplasty (a form of facial surgery that tightens and removes skin on the face and neck) can be found on the MBS. Cover will extend in situations;

• Where a patient has facial asymmetry due to a soft tissue abnormality
• Meloplasty due to;
  • congenital conditions
  • disease
  • Or, trauma. However, this excludes trauma caused by previous elective cosmetic surgeries.

Surgeries such as Facelifts, brow lifts and chin lifts are EXCLUDED. This is due to the fact that they are seen as purely elective cosmetic procedures.

Will Medicare cover Body Lift After Weight Loss?

Plastic surgery is very common after significant weight loss and is generally covered by Medicare. This is because there are valid medical reasons as to why the surgery is necessary.

Excess skin can not only interfere with regular activities and day-to-day living but it can also cause skin irritation, rashes and sores.  Surgery relating to the removal of redundant abdominal skin and fat as a direct result of large-scale weight loss is usually on the MBS.

This can also include radical abdominoplasty and other related procedures. However, in order for you to be eligible for cover, your weight must have been stable, for at least six months prior to surgery.

Download this Guide to understand Medicare and Health Insurance for Plastic Surgery in Victoria

You should always check the most up to date information via Medicare or contact our team at Coco Ruby Plastic Surgery on 1300 264 811 to discuss estimated out of pocket expenses for your specific surgery.  Our team can also give you information about our payment methods, which make plastic surgery even more accessible, with or without Medicare coverage.