Will Medicare Cover My Plastic Surgery in Melbourne VIC?
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.
Where can I find more information?
The full item descriptor(s) and information on other changes to the MBS can be found on the MBS Online website at www.mbsonline.gov.au.
Private health insurance information on the product tier arrangements is available at www.privatehealth.gov.au. Detailed information on the MBS item listing within clinical categories is available on the Department’s website.
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
- 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.
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 599 990 to discuss estimated out-of-pocket expenses for your specific surgery.
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.
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).
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. Abdominoplasty
- 30179 – Circumferential lipectomy (Torsoplasty) skin removal after massive weight loss, known also as Belt lipectomy
- 45569 – Closure of Abdodomioplasty with the reconstruction of umbilicus
- 45051 – Contour Defect Repair – Calf Augmentation / Pectoral Augmentation (Poland’s 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
- 41702 – Functional sinus surgery of the ostiomeatal unit
- 41703 – Functional sinus surgery, dissection of 5 sinuses and creation of single sinus cavity
- 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
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
Visit these Coco Ruby Blogs for more information about Medicare and Private Health Insurance
Will Medicare cover:
- Breast Reduction? or Breast Lift?
- Breast Implant Revision Surgery?
- Breast Implant Removal Surgery?
- Abdominoplasty After Weight Loss?
- Rhinoplasty & Nose Surgery?
- Eyelid Surgery – Blepharoplasty?
- Chin Surgery?
- Belt lipectomy?
- Thigh Lift?
- 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 General Practitioner 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 ( Royal Australasian College of surgeons ) 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 a cosmetic doctor.
Will Medicare cover my Abdominoplasty Surgery?
If you meet the strict criteria, Medicare will cover an Abdominoplasty – 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 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 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.
In order for you to be eligible for cover, your weight must have been stable, for at least six months prior to surgery.
You should always check the most up to date information via Medicare or contact our team at Coco Ruby Plastic Surgery on 1300 599 990 to discuss estimated out of pocket expenses for your specific surgery.