If you been thinking about getting plastic surgery there are some procedures that are covered by the Australian Medicare system and Private Health Insurers. When it comes to plastic surgery, the Medicare MBS guidelines are very specific.  Medicare will not cover ‘non-therapeutic cosmetic surgery’ like a cosmetic facelift or a boob job (breast augmentation). 

This means 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 deemed ‘medically necessary’ that meet their strict criteria. So which procedures are medically necessary and what are the specific criteria to meet?

Will My Private Health Fund Cover My Plastic Surgery Procedure?

If your surgery is covered by Medicare and has a valid item number and medical referral you may be able to get a subsidy from your Private Health Fund if you have the right level of cover (Gold, Silver, Bronze). Please contact your health fund and quote your medicare item number to find out. This subsidy can help offset your hospital fees, anaesthetist and assistant fees and some of the surgeon’s fee.

What is a valid ‘medically necessary’ reason for having plastic surgery?

A valid medical reason for Medicare to help cover the cost of your surgery can include things like:

  • Surgery following massive weight loss (removal of saggy skin, arm lift, abdominoplasty etc)
  • Female genital rejuvenation to correct for significantly enlarged labia causing discomfort and irritation (Labiaplasty)
  • Plastic surgery following skin cancer removal
  • Breast reconstruction following a mastectomy for breast cancer
  • Developmental breast asymmetry like tuberous breast anomaly and can include insertion, removal and replacement of breast implants
  • Facial reconstructive surgery after an accident or trauma

With other surgical procedures, the best way to find out if your own individual circumstances will be covered is to consult with a specialist medical professional to determine if you will be covered.

Medicare Item Numbers For Top Surgical Procedures Performed By Dr Carmen Munteanu Plastic Surgeon

To be eligible for the MBS Items patients must meet all the specific requirements as described within the Medicare Schedule and the item number may only be assigned by your chosen Specialist Plastic Surgeon. You will also need a valid medical referral from a GP or Specialist at the time of surgery.

The following listed Medicare Benefits Schedule (MBS) Item Numbers are essential for patients to be able to claim the Medicare rebates and utilise their Private Health Insurance Hospital cover for surgical procedures. There are also certain limitations to the eligibility such as age, past medical history, combining multiple procedures etc.

Please note these are just some of the Medicare Item Numbers and a very brief description only, please see all requirements and specific criteria on the MBS website detailed below.

Breast Surgery MBS Item Numbers

  • 45558   Breast Lift / Mastopexy
  • 45520   Breast Reduction Surgery Unilateral (Single side)
  • 45523   Breast Reduction Surgery Bilateral (both sides) 
  • 45548   Breast Implant Removal
  • 45551   Breast Implant Removal with Capsulectomy
  • 45553   Remove and Replace Breast Implants due to a complication
  • 45554   Remove and Replace Breast implants due to a complication
  • 45060   Breast Asymmetry or Tubular Breast surgery

Body Surgery  MBS Item Numbers

  • 30166 – Lipectomy / Excess Abdominal Skin Removal after Weight Loss
  • 30169 – Lipectomy / Excess Skin Removal for Non-Abdominal Skin – i.e. Arms or Legs
  • 30176 – Radical Abdominoplasty
  • 30177 – Lipectomy / Excess Abdominal Skin Removal after weight loss
  • 30175 – Abdominoplasty for Split Tummy Muscles
  • 30179   Circumferential lipectomy (Torsoplasty) skin removal after massive weight loss
  • 31525/31526 – Mastectomy for Gynaecomastia – Male Breast Reduction/ Contouring

Female Genital Surgery MBS Item Numbers

  • 35534   Labiaplasty / Vulvoplasty

Medicare Item Numbers & Descriptions As Stated In The Medicare Benefits Schedule (MBS) – In Detail

Breast Surgery Procedures

45060 Developmental breast abnormality, single-stage correction of, if: (a) the correction involves either: (i) bilateral mastopexy for symmetrical tubular breasts; or (ii) surgery on both breasts with a combination of insertion of one or more implants (which must have at least a 10% volume difference), mastopexy or reduction mammaplasty, if there is a difference in breast volume, as demonstrated by an appropriate volumetric measurement technique, of at least 20% in normally shaped breasts, or 10% in tubular breasts or in breasts with abnormally high inframammary folds; and (b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes. Applicable only once per occasion on which the service is provided

45520 Reduction mammaplasty (unilateral) with surgical repositioning of nipple, in the context of breast cancer or developmental abnormality of the breast, other than a service associated with a service to which item 31512, 31513 or 31514 applies on the same side (H)

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; other than a service associated with a service to which item 31512, 31513 or 31514 applies (H)

45548 Breast prosthesis, removal of, as an independent procedure

45551 Breast prosthesis, removal of, with excision of at least half of the fibrous capsule, not with insertion of any prosthesis. The excised specimen must be sent for histopathology and the volume removed must be documented in the histopathology report

45553  Breast prosthesis, removal of and replacement with another prosthesis, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture), if: (a) either: (i) it is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity; or (ii) the original implant was inserted in the context of breast cancer or developmental abnormality; and (b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

45554 Breast prosthesis, removal and replacement with another prosthesis, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture), including excision of at least half of the fibrous capsule or formation of a new pocket, or both, if: (a) either:(i) it is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity; or (ii) the original implant was inserted in the context of breast cancer or developmental abnormality; and (b) the excised specimen is sent for histopathology and the volume removed is documented in the histopathology report; and (c) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

45558

Correction of bilateral breast ptosis by mastopexy, if:

(a) at least two‑thirds of the breast tissue, including the nipple, lies inferior to the inframammary fold where the nipple is located at the most dependent, inferior part of the breast contour; and

(b) 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, other than a service associated with a service to which item 31512, 31513 or 31514 applies

NOTE – Item 45558 should not be used with the insertion of any prosthesis. i.e. a breast implant.

31525 Breast, mastectomy for gynecomastia, with or without liposuction (suction assisted lipolysis), not being a service associated with a service to which item 45585 applies

Body Surgery Procedures

Medicare Item Numbers for Body Procedures

30166 – Removal of redundant abdominal skin and lipectomy, as a wedge excision, for functional problems following significant weight loss equivalent to at least 5 body mass index points and if there has been a stable weight for a period of at least 6 months prior to surgery, other than a service associated with a service to which item 30175, 30176, 30177, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies (H)

30169 – Removal of redundant non-abdominal skin and lipectomy for functional problems following significant weight loss equivalent to at least 5 body mass index points and if there has been a stable weight for a period of at least 6 months prior to surgery, one or 2 non-abdominal areas, other than a service associated with a service to which item 30175, 30176, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies (H)

30176 – Radical abdominoplasty, with excision of skin and subcutaneous tissue, repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30166, 30169, 30175, 30177, 30179, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070 or 46072 applies, if the patient has previously had a massive intra-abdominal or pelvic tumour surgically removed (H)

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, with or without repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30166, 30175, 30176, 30179, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 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

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, not being a service associated with a service to which item 30175, 30176, 30177, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 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

Body Procedures – for Gynaecomastia / Male Chest Contouring

31525 – Mastectomy for gynaecomastia (unilateral), with or without liposuction (suction assisted lipolysis), if:
(a) breast enlargement is not due to obesity and is not proportionate to body habitus; and
(b) sufficient photographic evidence demonstrating the clinical need for the service is included in patient notes;
not being a service associated with a service to which item 45585 applies (H)

31526 – Mastectomy for gynaecomastia (bilateral), with or without liposuction (suction assisted lipolysis), if:
(a) breast enlargement is not due to obesity and is not proportionate to body habitus; and
(b) sufficient photographic evidence demonstrating the clinical need for the service is included in patient notes;
not being a service associated with a service to which item 45585 applies (H)

Body Surgery Procedures – Post-Pregnancy Abdominoplasty for Split Tummy Muscles

30175 – Radical abdominoplasty, with repair of rectus diastasis, excision of skin and subcutaneous tissue, and transposition of umbilicus, not being a laparoscopic procedure, if:
(a) the patient has an abdominal wall defect as a consequence of pregnancy; and
(b) the patient: (i) has a diastasis of at least 3cm measured by diagnostic imaging prior to this service; and (ii) has either or both of the following:

(A) at least moderately severe pain or discomfort at the site of the diastasis in the abdominal wall during functional use and the pain or discomfort has been documented in the patient’s records by the practitioner providing the service;
(B) low back pain or urinary symptoms likely due to rectus diastasis and the pain or symptoms have been documented in the patient’s records by the practitioner providing the service; and

(iii) has failed to respond to non-surgical conservative treatment, that must have included physiotherapy; and (iv) has not been pregnant in the last 12 months; and (c) the service is not a service associated with a service to which item 30166, 30169, 30176, 30177, 30179, 30651, 30655, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies
Applicable once per lifetime (H)

Female Genital Surgery Procedures

35534 Vulvoplasty or labioplasty, in a patient aged 18 years or more, performed by a specialist in the practice of the specialist’s specialty, for a structural abnormality that is causing significant functional impairment, if the patient’s labium extends more than 8 cm below the vaginal introitus while the patient is in a standing resting position