Does Medicare Cover my Surgery?

Medicare coverage for plastic surgery in Australia

For patients undergoing plastic surgery in Australia, understanding the role of Medicare item numbers is essential. These item numbers, assigned by the Medicare Benefits Schedule (MBS), are used to determine whether a medical procedure qualifies for Medicare rebates. For procedures to be eligible, they must meet specific criteria, particularly in cases of reconstructive or medically necessary surgery.

What are Medicare item numbers?

Medicare item numbers are unique codes listed in the Medicare Benefits Schedule (MBS). These numbers identify various medical services and procedures that the Australian government considers necessary for patient health. The item numbers allow patients to claim Medicare rebates and possibly a Health Insurance contribution to cover part of the cost of the procedure. This can help reduce your out-of-pocket expenses.

Which surgeries can qualify for Medicare?

While purely cosmetic surgeries are not covered by Medicare, medically necessary plastic and reconstructive surgeries often are. For surgery to qualify, it must serve a functional purpose or address significant health concerns rather than purely aesthetic improvements. Common examples include:

• Breast reduction surgery for relief of medical symptoms such as back or neck pain
• Breast Implant Removal or Replacement for some implant complications
• Abdominoplasty for patients with significant abdominal muscle separation post-pregnancy (diastasis recti)
• Excess Skin Removal Surgery after massive weight loss – e.g. Armlift, Thighlift or Lower Body lift
• Gynecomastia Surgery – for male breast removal
• Skin cancer removal and reconstruction
• Rhinoplasty or Septoplasty for correction of breathing difficulties
• Blepharoplasty (eyelid surgery) where vision is impaired due to drooping eyelids
• Breast reconstruction following mastectomy for breast cancer

Eligibility and MBS criteria

Each procedure covered by Medicare has strict MBS criteria that must be met. For instance, breast reduction surgery (MBS item number 45520) requires evidence of functional problems such as rashes, back pain, or posture issues. Without meeting these criteria, the surgery is considered elective, and Medicare rebates will NOT apply.

The MBS is updated periodically, and it is crucial for both surgeons and patients to remain aware of changes to the item numbers and the eligibility requirements. Surgeons can guide patients through the MBS process, providing the necessary documentation and evidence of medical necessity to support the claim.

How to use Medicare item numbers for surgery

1. Consultation and Assessment: Your surgeon will assess whether your condition meets the criteria for a Medicare rebate. This includes reviewing medical history, symptoms, and physical examinations.
2. Medicare Item Number Assignment: If the surgery qualifies, the surgeon will assign an appropriate Medicare item number from the MBS. This number will be included in your medical documentation and future Medicare claims.
3. Obtaining a Referral: A valid GP or specialist referral is necessary before proceeding with surgery to ensure eligibility under Medicare. The physician will provide a medical reason for the surgery, further supporting the claim for a rebate.
4. Making a Claim: After the procedure, your surgeon’s office will assist in making a Medicare claim using the assigned item number. Medicare will then reimburse part of the cost depending on the service.

Commonly used plastic surgery item numbers

Here are some examples of Medicare item numbers for common plastic and reconstructive surgeries:

• 104 & 105: for medical consultation and patient reviews
• 45523: Breast reduction surgery for symptomatic relief.
• 45558: Breast lift surgery – mastopexy
• 45553 & 45554: Breast Implant removal & replacement after a complication
• 45548: Breast Implant removal
• 30175: Abdominoplasty for diastasis recti in post-pregnancy women.
• 30177: Abdominoplasty after Massive Weight Loss
• 31525 or 31526: Gynaecomastia (unilateral or bilateral)
• 45632 to 45644, and 45650: Rhinoplasty for nasal obstruction or breathing difficulties.
• 45618: Blepharoplasty for visual field defects
• 45060: Skin cancer removal with reconstructive surgery.

These item numbers are subject to change, so it’s essential to consult with your surgeon and check the most current MBS information.

Why Medicare rebates matter

Having surgery covered by Medicare can save you significant costs. The ability to claim these procedures under Medicare ensures that medical care remains more accessible to all Australians.

However, not all surgeries will be fully covered by Medicare, and patients should be aware that there may still be out-of-pocket expenses such as surgeon’s fees, hospital costs, or anaesthesia fees. Private health insurance can help offset these costs if you hold a suitable policy.

For more detailed information or assistance with determining eligibility for your surgery, you can refer to your surgeon or visit the Medicare Benefits Schedule (MBS) or Item Number Search online.