Will Medicare cover my surgery?

If you have a valid medical referral and meet the strict criteria for a Medicare item number, then you may receive a Medicare rebate and could be eligible for a subsidy from your Private Health Insurance fund.

Medicare will not cover purely cosmetic surgery but some breast, body, nose and face surgery is regarded as medically necessary and you can qualify for a rebate if you have a valid medical reason.

It’s recommended to consult the latest Medicare guidelines or contact Medicare directly to inquire about any recent updates or changes regarding the subsidisation of abdominoplasty procedures.

For more detailed information about Medicare and your Procedure please read the blogs below.

• Medicare for Breast Reduction Surgery in Sydney
• Medicare for Breast Lift Surgery in Sydney
• Medicare for Eyelid Surgery – Blepharoplasty in Sydney
• Medicare for Gynaecomastia – Male Breast Reduction Surgery
• Medicare for Gender Affirmation Surgery in Sydney
• Medicare for Fleur De Lis Surgery – Abdominoplasty (Tummy Tuck) in Sydney
• Medicare for Thigh Lift Surgery
• Medicare for Body Lift Surgery – Excess Skin Removal after Weight Loss
• Medicare for Arm Lift Surgery
• Medicare Item Numbers for Skin and Hand Surgery

Medicare item code number update

New 30175 Medicare item number to subsidise some Abdominoplasty procedures

The Australian government has reinstated a Medicare item number for an abdominoplasty for some post-pregnancy patients suffering from Diastasis Recti (split tummy muscles) if you are eligible and meet the new criteria. 

This new 30175 Medicare Item Number is effective from 1st July 2022. Read the factsheet.

30175 Radical abdominoplasty, with the repair of rectus diastasis, excision of skin and subcutaneous tissue, and transposition of the umbilicus, not being a laparoscopic procedure, where the patient has an abdominal wall defect as a consequence of pregnancy, if the patient:

• has a diastasis of at least 3cm measured by diagnostic imaging before this service; and
• has symptoms of at least moderate severity of pain or discomfort at the site of the diastasis in the abdominal wall during functional use and/or low back pain or urinary symptoms likely due to rectus diastasis that has been documented in the patient’s records by the practitioner providing this service; and
• has failed to respond to non-surgical conservative treatment including physiotherapy; and
• has not been pregnant in the last 12 months the service is not a service associated with a service to which item
  30165, 30651, 30655, 30168, 30171, 30172, 30176, 30177, 30179, 45530, 45564 or 45565 
  applies. Applicable once per lifetime – (H) (Anaes.) (Assist.)

If you qualify for the 30175 Medicare item number you may also get a subsidy from your Health Fund. There will still be a significant out-of-pocket gap as private abdominoplasty surgery is NOT free. 

What is a valid medical reason for plastic surgery?

A valid medical reason for surgery can include things like:

• Facial reconstructive surgery after an accident or trauma
• Nose Surgery to rectify an obstructed nasal passage or breathing issue
• Breast reconstruction following a mastectomy or removal/replacement of an implant
• Breast Surgery for overly large or sagging breasts
• Post Weight Loss Skin Removal Surgery following massive weight loss (removal of excess loose skin, abdominoplasty and such)
• Plastic surgery following skin cancer removal, cancer or some minor skin surgery

To find out if you will be covered by Medicare you should consult with a qualified medical professional or specialist surgeon.

Consulting a Medical Specialist

If you are seeking plastic surgery for a valid medical reason, the first step is to obtain a referral letter from your GP to go and see a medical specialist.  In order to be covered by Medicare, you need to ensure that the specialist you’re referred to is an accredited surgeon.

REMEMBER

Plastic Surgeons and Cosmetic Surgeons are completely different doctors. Even though they sound similar – they are different- and this makes a big difference when it comes to Medicare. Medicare will only cover you if you approach a fully-trained and qualified FRACS surgeon.

Is my procedure covered by Medicare?

The Medicare Benefits Schedule (MBS) is searchable online and is a resource to use if you’re doing preliminary research about your chosen procedure. You can find out the criteria and the medicare rebate.

Visit the Medicare Item Number Website (MBS)

Dr. Kernohan’s most popular Medicare item numbers in detail

Surgeon consultation and review item numbers

• 104  FIRST CONSULTATION  Professional attendance at consulting rooms or hospitals by a specialist in the practice of the specialist’s specialty after referral of the patient to the specialist-each attendance, other than a second or subsequent attendance, in a single course of treatment, other than a service to which item 106, 109 or 16401 applies
• 105  REVIEW CONSULTATION    Professional attendance by a specialist in the practice of the specialist’s specialty following referral of the patient to the specialist-an attendance after the first in a single course of treatment, if that attendance is at consulting rooms or hospital, other than a service to which item 16404 applies
• 91832  FIRST TELECONSULT Phone attendance for a person by a specialist in the practice of the specialist’s specialty if: (a) the attendance follows referral of the patient to the specialist; and (b) the attendance was of more than 5 minutes in duration. Where the attendance was other than a second or subsequent attendance as part of a single course of treatment.
• 91833  REVIEW TELECONSULT Phone attendance for a person by a specialist in the practice of the specialist’s specialty if: (a) the attendance follows referral of the patient to the specialist; and (b) the attendance was of more than 5 minutes in duration. Where the attendance is after the first attendance as part of a single course of treatment.

Body surgery Medicare item numbers

• 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. ( NEW from July 1st 2022)
• 30177   Lipectomy, excision of skin and subcutaneous tissue associated with redundant abdominal skin and fat that is a direct consequence of significant weight loss, in conjunction with a radical abdominoplasty (Pitanguy type or similar), with or without repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30176, 30179, 45530, 45564 or 45565 applies, if: (a) there is intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non surgical) treatment; and (b) the redundant skin and fat interferes with the activities of daily living; and (c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy (H) (Anaes.) (Assist.)
• 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, with or without a radical abdominoplasty (Pitanguy type or similar),not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30176, 30177, 45530, 45564 or 45565 applies, if: (a) the circumferential excess of redundant skin and fat is complicated by intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non surgical) treatment; and (b) the circumferential excess of redundant skin and fat interferes with the activities of daily living; and (c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy (H) (Anaes.) (Assist.)
• 45569   CLOSURE OF ABDOMEN WITH RECONSTRUCTION OF UMBILICUS, with or without lipectomy, being a service associated with items 45562, 45564, 45565 or 45530 (Anaes.) (Assist.)
• 45570   CLOSURE OF ABDOMEN, repair of musculoaponeurotic layer, being a service associated with item 45569 (Anaes.) (Assist.)
• 45584   Liposuction (suction assisted lipolysis) to one regional area (one limb or trunk), for treatment of post traumatic pseudolipoma, if photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes (Anaes.)

Breast surgery Medicare item numbers

• 45523   Reduction mammaplasty (bilateral) with surgical repositioning of the nipple: (a) for patients with macromastia and experiencing pain in the neck or shoulder region; and (b) not with insertion of any prosthesis (Anaes.) (Assist.)
• 45558   Breast ptosis, correction by mastopexy of (bilateral), if: (a) at least two-thirds of the breast tissue, including the nipple, lies inferior to the infra-mammary fold where the nipple is located at the most dependent, inferior part of the breast contour; and (b) if the patient has been pregnant—the correction is performed not less than 1 year, or more than 7 years, after completion of the most recent pregnancy of the patient; and (c) photographic evidence (including anterior, left lateral and right lateral views), with a marker at the level of the inframammary fold, demonstrating the clinical need for this service, is documented in the patient notes Applicable only once per lifetime (Anaes.) (Assist.) – NOTE – the criteria referencing pregnancy has been removed since 1 Nov 2021.

• 31525 MALE BREAST REDUCTION – BREAST, mastectomy for gynecomastia, with or without liposuction (suction-assisted lipolysis), not being a service associated with a service to which item 45585 applies (H)

Nose surgery Medicare item numbers

• 45641   Rhinoplasty, total, including correction of all bony and cartilaginous elements of the external nose, with or without autogenous cartilage or bone graft from a local site (nasal), if: (a) the indication for surgery is: (i) airway obstruction and the patient has a self‑reported NOSE Scale score of greater than 45; or (ii) significant acquired, congenital or developmental deformity; and (b) photographic and/or NOSE Scale evidence demonstrating the clinical need for this service is documented in the patient notes (Anaes.)
• 45650   Rhinoplasty, revision of, if: (a) the indication for surgery is: (i) airway obstruction and the patient has a self-reported NOSE Scale score of greater than 45; or (ii) significant acquired, congenital or developmental deformity; and (b) photographic and/or NOSE Scale evidence demonstrating the clinical need for this service is documented in the patient notes (Anaes.)
• 47738   NASAL BONES, treatment of fracture of, by reduction (Anaes.)

Facial Palsy and Facial Nerve Surgery Medicare item numbers

• 11018   NEUROMUSCULAR ELECTRODIAGNOSIS conduction studies on 4 or more nerves with or without electromyography OR recordings from single fibres of nerves and muscles OR both of these examinations (not being a service associated with a service to which item 11012 or 11015 applies)
• 39330   NEUROLYSIS by open operation without transposition, not being a service associated with a service to which item 39312 applies (Anaes.) (Assist.)
• 45588   Meloplasty (excluding browlifts and chinlift platysmaplasties), bilateral, if: (a) surgery is indicated to correct a functional impairment due to a congenital condition, disease (excluding post-acne scarring) or trauma (other than trauma resulting from previous elective cosmetic surgery); and (b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes (Anaes.) (Assist.)

Arm and Thigh Surgery Medicare item numbers.

• 18266   ULNAR, RADIAL OR MEDIAN NERVE, MAIN TRUNK OF, 1 or more of, injection of an anaesthetic agent, not being associated with a brachial plexus block
• 30171 – Lipectomy for Arm lift or Thigh lift

Ear correction surgery Medicare item numbers

• 45659   Correction of a congenital deformity of the ear if: (a) the patient is less than 18 years of age; and (b) the deformity is characterised by an absence of the antihelical fold and/or large scapha and/or large concha; and (c) photographic evidence demonstrating the clinical need for this service is documented in the patient notes (Anaes.) (Assist.)

Eye surgery Medicare item numbers

• 42590   CANTHOPLASTY, medial or lateral (Anaes.) (Assist.)
• 42866   ENTROPION or TARSAL ECTROPION, repair of, by tightening, shortening or repair of inferior retractors by open operation across the entire width of the eyelid (Anaes.) (Assist.)
• 42869   EYELID closure in facial nerve paralysis, insertion of foreign implant for (Anaes.) (Assist.)
• 42872   EYEBROW, elevation of, by skin excision, to correct for a reduced field of vision caused by paretic, involutional, or traumatic eyebrow descent/ptosis to a position below the superior orbital rim (Anaes.)
• 45590   ORBITAL CAVITY, reconstruction of a wall or floor, with or without foreign implant (Anaes.) (Assist.)
• 45617   Upper eyelid, reduction of, if: (a) the reduction is for any of the following: (i) skin redundancy that causes a visual field defect (confirmed by an optometrist or ophthalmologist) or intertriginous inflammation of the eyelid; (ii) herniation of orbital fat in exophthalmos; (iii) facial nerve palsy; (iv) post-traumatic scarring; (v) the restoration of symmetry of contralateral upper eyelid in respect of one of the conditions mentioned in subparagraphs (i) to (iv); and (b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes (Anaes.)
• 45623  EYELID PTOSIS Ptosis of upper eyelid (unilateral), correction of, by: (a) sutured elevation of the tarsal plate on the eyelid retractors (Muller’s or levator muscle or levator aponeurosis); or (b) sutured suspension to the brow/frontalis muscle; Not applicable to a service for repair of mechanical ptosis to which item 45617 applies (Anaes.) (Assist.)
• 42610   NASOLACRIMAL TUBE (unilateral), removal or replacement of, or LACRIMAL PASSAGES, probing for obstruction, unilateral, with or without lavage – under general anaesthesia (Anaes.)
• 45665   LIP, EYELID OR EAR, FULL THICKNESS WEDGE EXCISION OF, with repair by direct sutures (Anaes.)