Medicare for Plastic Surgery

Medicare Item numbers for Plastic Surgery Procedures

When considering plastic surgery in Australia, one of the first questions you might have is whether Australian Medicare and Private Health Insurance will cover your procedure. 

Medicare does provide coverage for certain medically necessary plastic surgery procedures, but it’s essential to understand the specifics to avoid unexpected costs.

Medicare Coverage for Plastic Surgery

Medicare covers a wide range of medical services, including some plastic surgery procedures. However, it’s important to understand that not all plastic surgery is treated equally under Medicare. The main distinction lies in whether a procedure is considered medically necessary or is purely cosmetic.

Medicare will only cover plastic surgery procedures that are deemed medically necessary. These typically include reconstructive surgeries following accidents, burns, or cancer treatments, as well as procedures to alleviate congenital abnormalities or increase bodily functions.

On the other hand, cosmetic procedures, which are primarily aimed at altering appearance without addressing a medical issue, are not covered by Medicare. This category often includes treatments like facelifts, breast augmentations for aesthetic reasons, or liposuction for body contouring.

It’s important to note that the line between medically necessary and cosmetic procedures can sometimes be blurry. Some procedures may fall into a grey area, where they have both functional and aesthetic benefits. In these cases, Medicare coverage may depend on strict criteria, your specific circumstances and the assessment of your plastic surgeon.

The distinction between cosmetic and reconstructive procedures is important not only for Medicare coverage but also for your out-of-pocket expenses. Procedures covered by Medicare will typically cost you less, as a portion of the expenses may be covered by your Private Health Insurance.

Medicare Item Numbers for Plastic Surgery

To understand how Medicare coverage works for plastic surgery, you need to be familiar with Medicare item numbers. These are unique codes assigned to specific medical services and procedures recognised by Medicare Australia. Each item number corresponds to a particular treatment and has an associated schedule fee, which is the amount Medicare has determined as appropriate for that service.

For plastic surgery procedures, these item numbers play a role in determining whether and how much Medicare will contribute to the cost of your treatment. If your procedure has an associated Medicare item number, it means that Medicare recognises it as a potentially necessary medical treatment, rather than a purely cosmetic one.

However, having an item number doesn’t automatically guarantee coverage. The amount you’ll receive back from Medicare can vary depending on several factors, including whether the procedure was performed in a public or private hospital, and whether you have reached your Medicare Safety Net threshold.

It’s also worth noting that some procedures may involve multiple item numbers, especially if they are complex or involve several steps. When consulting with Dr Kohout, he can provide you with the relevant item numbers for your procedure. This information allows you to check with Medicare about potential rebates and gives you a clearer picture of your likely out-of-pocket expenses.

While Medicare item numbers are a good indicator of potential coverage, the final decision on eligibility often depends on your individual circumstances and the specifics of your case.

Plastic Surgery Procedures Covered by Medicare

Medicare coverage for plastic surgery procedures in Australia is primarily based on medical necessity. Here are some common procedures that may be eligible for Medicare benefit:

Breast Procedures

Medicare Item Numbers for breast reduction surgery:

• MBS Item 45520: Reduction mammaplasty (unilateral), with surgical repositioning of nipple, in the context of breast cancer or developmental abnormality when performed for medical reasons. This item usually requires specific clinical justification, such as chronic pain or physical discomfort due to large breasts.
• MBS Item 45523: Reduction mammaplasty (bilateral), for the same reasons as Item 45520, but for both breasts.

Eligibility for Medicare coverage is usually determined by factors such as:

• Chronic pain or discomfort (e.g., neck, back, or shoulder pain).
• Skin issues (such as infections or rashes under the breast fold).
• Functional limitations (difficulty with physical activity or finding appropriately sized clothing).

Medicare Item Numbers that may apply to breast lift surgery:

• MBS Item 45558 – Mastopexy (Breast Lift): This item covers breast lift (mastopexy) surgery when performed to correct breast ptosis (drooping). It requires documented clinical need through photographic evidence.
• MBS Item 45556 – Breast ptosis, correction of (unilateral), in the context of breast cancer or developmental abnormality.
• MBS Item 45060 covers the single-stage correction of developmental breast abnormalities. This includes bilateral mastopexy for symmetrical tubular breasts and surgery with implants for breast asymmetry, with certain volumetric differences. It requires documented clinical need through photographic or diagnostic evidence. It applies only once per occasion of service.

Abdominal Procedures

• MBS Item 30166: Removal of redundant abdominal skin following significant weight loss.
• MBS Item 30175: Radical abdominoplasty, with repair of rectus diastasis (usually after pregnancy – requiring documented separation evidence prior to surgery).
• MBS Item 30176: Radical abdominoplasty, with excision of skin and subcutaneous tissue, repair of musculoaponeurotic layer and transposition of umbilicus.
• MBS Item 30177: Lipectomy, excision of skin and subcutaneous tissue associated with redundant abdominal skin and fat that is a direct consequence of significant weight loss.
• MBS Item 30179: Circumferential lipectomy, as an independent procedure, to correct circumferential excess of redundant skin and fat that is a direct consequence of significant weight loss.
• MBS Item 30169: Removal of redundant non-abdominal skin (thighs, arms), typically post-weight loss.

Face Procedures

• MBS Item 45617 – Upper Eyelid Surgery: This item is for upper eyelid surgery (blepharoplasty) performed to correct vision impairment caused by drooping eyelids (ptosis), where excess skin obstructs the field of vision.
• MBS Item 45620 – Lower Eyelid Surgery: This item covers lower eyelid surgery, generally performed to correct medical issues such as ectropion (outward turning of the eyelid), entropion (inward turning), or other conditions that affect eyelid function.

How to Determine if Your Procedure is Covered

Determining whether your plastic surgery procedure is covered by Medicare involves several steps:

• Consult with Dr Kohout: The first step is to have a thorough consultation with Dr Mark Kohout. As an experienced plastic surgeon, he can assess your individual case and provide advice on whether your procedure might be eligible for Medicare coverage. Keep in mind that you need a GP referral to see Dr Kohout.
• Understand the medical necessity: Medicare covers procedures that are deemed medically necessary. Dr Kohout can help you understand whether your desired procedure falls into this category. He’ll consider factors such as physical discomfort, functional impairment, or significant deformity resulting from congenital issues, trauma, or disease.
• Get the relevant Medicare item numbers: If Dr Kohout believes your procedure may be eligible for Medicare benefits, he’ll provide you with the relevant Medicare item numbers. These are essential for checking your coverage.
• Get the necessary documentation: If your procedure is potentially eligible for Medicare benefits, you may need to provide documentation supporting its medical necessity. This could include referrals from your GP, reports from specialists, or test results demonstrating functional impairment.

Remember, eligibility for Medicare coverage is determined on a case-by-case basis. Even if a procedure is generally covered, your individual circumstances will be taken into account.

Out-of-Pocket Costs

Even when a plastic surgery procedure is covered by Medicare, you should be prepared for potential out-of-pocket costs. Here’s what you need to know:

• Medicare Schedule Fee: Medicare sets a schedule fee for each item number. This is the amount Medicare considers appropriate for the service.
• Medicare Benefit: In most cases, Medicare pays 75% of the schedule fee for in-hospital services and 85% for out-of-hospital services.
• Gap Payment: The difference between the Medicare benefit and the actual fee charged by the surgeon is known as the “gap”. You’re responsible for paying this gap, unless you have private health insurance that contributes towards it.
• Hospital Fees: If your procedure is performed in a private hospital, you’ll likely have out-of-pocket expenses for hospital fees, unless you have the appropriate level of private health insurance.  It’s important to check – don’t just assume you are covered.
• Anaesthetist Fees: The anaesthetist’s fees are separate from the surgeon’s fees and may also involve out-of-pocket costs.
• Medicare Safety Net: Once you reach a certain threshold of out-of-pocket expenses in a calendar year, the Medicare Safety Net may provide additional benefits, reducing your costs for the rest of the year.
• Prostheses and Implants: If your procedure involves prostheses or implants, these may not be fully covered by Medicare and could result in additional out-of-pocket expenses.

Dr Kohout and his team will provide you with a detailed quote and informed financial consent, including estimated out-of-pocket costs, before you proceed with any procedure.

Private Health Insurance and Plastic Surgery

Private health insurance can play a role in plastic surgery coverage, often complementing Medicare benefits:

• Increased Coverage: Private health insurance may cover a portion of the costs for Medicare-covered procedures.
• Choice of Surgeon and Hospital: With private insurance, you typically have more choice in selecting your surgeon and hospital.
• Shorter Wait Times: For elective procedures, private insurance often means shorter wait times compared to the public system.
• Hospital Expenses: Private health insurance usually covers hospital expenses for inpatient treatments, which can be a significant cost for plastic surgery procedures.
• Prostheses and Implants: Some private health insurance policies may cover prostheses and implants used in plastic surgery procedures.

When considering private health insurance for plastic surgery:

• Check your policy details: Understand what procedures are covered, any waiting periods, and what level of cover you have.
• Discuss with your insurer: Contact your health fund to confirm coverage for specific procedures and understand any out-of-pocket costs. Do not just assume you are covered only to find out in the days leading up to the procedure that you have significant out-of-pocket expenses.
• Consider upgrading: If you’re planning a procedure not covered by your current policy, you might consider upgrading your coverage. Be aware of waiting periods for new or upgraded policies.
• Understand pre-existing condition rules: If your plastic surgery is related to a pre-existing condition, there may be additional waiting periods.