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, in other words, Medicare will not cover elective surgeries that you choose to pursue purely for 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?

The term ‘medically necessary can seem vague, however, it can include things like:

Plastic surgery following skin cancer removal
Facial reconstructive surgery after either an accident or trauma
As well as, a rhinoplasty to rectify an obstructed nasal passage
Breast reconstruction following a mastectomy or removal/replacement of an implant
Correction of either congenital or breast developmental disorders like tuberous or asymmetric breasts
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, of course, to consult with a medical professional.

All Procedures on Medicare MBS

Some of the other procedures on the MBS are detailed below, however, this is not all of them, there are many other item numbers.

You should always check the most up to date information via Medicare. You can also 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 either Breast Asymmetry or Tubular Correction single stage
45061 – BA/BR for either Breast Asymmetry or Tubular Correction – 2 stage, part 1
45062 – BA/BR for either Breast 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 in other words, 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 (From 1 November 2021, the descriptor for item 45558 has been amended to remove references to pregnancy. This change will not only clarify but also open access to the patient populations at greatest need of the service, including individuals who have undergone significant weight loss.)

Breast Reconstruction MBS Item Numbers

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

Fat Grafting to Breast, Face or Body for reconstructive purposes or congenital deformities

45534 – Autologous fat grafting, unilateral service for breasts
45535 – Autologous fat grafting, bilateral service for breasts
45589 – Autologous fat grafting for craniofacial or burns

Note these new Medicare Item Numbers are for Fat Grafting for either reconstruction or correction of developmental deformities like asymmetry or tuberous breasts – Not for purely cosmetic surgery like a breast augmentation.

From 1 November 2021 three NEW medicare item numbers for the provision of surgical treatment by autologous fat grafting have been introduced as a result of ASPS and BreastSurg ANZ’s successful MSAC applications.

45535

Autologous fat grafting, bilateral service (harvesting, preparation and injection of adipocytes) if: (a) the autologous fat grafting is for one or more of the following purposes: (i) the correction of defects arising from treatment and prevention of breast cancer in patients with contour defects, greater than or equal to 20% volume asymmetry, post-treatment pain or poor prosthetic coverage; (ii) the preparation of post-mastectomy thin or irradiated skin flaps in patients intending to have breast reconstruction; (iii) breast reconstruction in breast cancer patients; (iv) the correction of developmental disorders of the breast; and (b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes Up to a total of 4 services.

45534 Autologous fat grafting, unilateral service (harvesting, preparation and injection of adipocytes) if: (a) the autologous fat grafting is for one or more of the following purposes: (i) the correction of defects arising from treatment and prevention of breast cancer in patients with contour defects, greater than or equal to 20% volume asymmetry, post-treatment pain or poor prosthetic coverage; (ii) the preparation of post-mastectomy thin or irradiated skin flaps in patients intending to have breast reconstruction; (iii) breast reconstruction in breast cancer patients; (iv) the correction of developmental disorders of the breast; and (b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes Up to a total of 4 services per side (for a total treatment of a single breast).

Item Number 45589

Autologous fat grafting (harvesting, preparation and injection of adipocytes) if: (a) the autologous fat grafting is for either or both of the following purposes: (i) the correction of asymmetry arising from volume and contour defects in craniofacial disorders—up to a total of 4 services if each service is provided at least 3 months after the previous service; (ii) the treatment of burn scar or associated skin graft in the context of scar contracture, contour deformity or neuropathic pain, for patients who have undergone a minimum of 3 months of topical therapies, including silicone and pressure therapy, with an unsatisfactory or minimal level of improvement—up to a total of 4 services per region of the body (upper or lower limbs, trunk, neck or face) if each service provided per region of the body is provided at least 3 months after the previous such service; and

(b) both: (i) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes; and (ii) for craniofacial disorders, evidence of diagnosis of the qualifying craniofacial disorder is documented in the patient notes.

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)
30175 – Radical abdominoplasty, with repair of rectus diastasis, excision of skin and subcutaneous tissue, and transposition of umbilicus, not being a laparoscopic procedure, where the patient has an abdominal wall defect as a consequence of pregnancy. (from July 1st 2022)
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, known also as 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 – Either umbilical, epigastric or linea alba Hernia Repair
30648 – repair of either 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 the repair of either 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 lesion Removal MBS Item Numbers, however, Coco Ruby does not offer these procedures

Other Surgery that may be covered by Medicare

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 either trauma, burns or acne
Carbon dioxide laser or erbium laser resurfacing of the face or neck for severely disfiguring scarring resulting from either burns, trauma or acne
Weight Loss Surgery, where clinical morbid obesity has been diagnosed (See New Body Specialists for details about both surgeons and medicare coverage of bariatric surgery)
Both cleft lip and cleft palate surgery

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

Will medicare cover:

Coco Ruby Blog - Claiming Breast Implant Removal on Medicare Image Illustration

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. Both Medicare and your Health Fund will only cover you if you approach a fully-trained and qualified accredited surgeon, not just a cosmetic doctor.

Coco Ruby Blog - Belt Lipectomy Coverage of Medicare Image banner

Is my procedure covered by Medicare?

The Medicare Benefits Schedule (MBS) is searchable online. Furthermore, it is a great resource if you’re doing some preliminary research about your chosen procedure. Below 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/Tummy Tuck – find out more in this blog.

Will Medicare cover my Breast Surgery?

Breast reduction mammoplasty either 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 either 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. Furthermore, 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 either ‘lop ear’, ‘bat ear’ or, other similar deformities.

Will Medicare Cover Face Surgery?

Meloplasty (a form of facial surgery that both 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 either 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 can also cause skin irritation, rashes and sores. Therefore, 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.