Does Medicare Cover my Procedure? – Popular Medicare Item Numbers for Plastic Surgery with Dr Carmen

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’. 

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:

  • Breast reconstruction following a mastectomy for breast cancer or developmental breast asymmetry like tuberous breast anomaly and can include insertion, removal and replacement of breast implant
  • Facial reconstructive surgery after an accident or trauma
  • Surgery following massive weight loss (removal of saggy skin, arm liftabdominoplasty etc)
  • Excess Skin over your eyelid causing specific difficulties with vision (for Blepharoplasty)
  • Female genital rejuvenation to correct for significantly enlarged labia causing discomfort and irritation (Labiaplasty)
  • Plastic surgery following skin cancer removal

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 detailed below.

Breast Surgery MBS Item Numbers

  • 45060   Breast Asymmetry or Tubular Breast surgery
  • 45520   Breast Reduction Surgery Unilateral (Single side)
  • 45523   Breast Reduction Surgery Bilateral (both sides) 
  • 45548   Removal of Breast Implant
  • 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
  • 45558   Breast Lift / Mastopexy
  • 31519   Mastectomy / Total Removal of Breasts
  • 31525   Mastectomy for Gynecomastia – excision of Breast Tissue (Male Breast Reduction)
  • 31563   Inverted Nipple Correction

Body Surgery post Weight loss MBS Item Numbers

  • 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)
  • 30177   Lipectomy skin removal after weight loss – e.g. Tummy Tuck / Abdominoplasty
  • 30179   Circumferential lipectomy (Torsoplasty) skin removal after massive weight loss

Facial Surgery – Eye / Ear Correction MBS Item Numbers

  • 42590  Canthoplasty
  • 45617 Eyelid Reduction
  • 45659  Otoplasty – Ear Deformity Correction

Female Genital Surgery MBS Item Numbers

  • 35534   Labiaplasty / Vulvoplasty

Scar Revisions MBS Item Numbers

  • 45506  Scar Revision to Face
  • 45512  Scar Revision to Face
  • 45515  Scar Revision to Body
  • 45518  Scar Revision to Body
MBS Item Numbers for Plastic Surgery - Breast Surgery - Body Surgery - Eyelift Surgery - Nose Surgery
Find more detail about Medicare Item Numbers on the MBS website (Below).

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

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

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

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 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

31519  Breast, total mastectomy 

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

31563  Inverted nipple, surgical eversion of

Body Surgery Procedures

30171 Lipectomy, wedge excision of redundant non abdominal skin and fat that is a direct consequence of significant weight loss, not being a service associated with a service to which item 30165, 30168, 30172, 30176, 30177, 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; and (d) the procedure involves 2 excisions only

30172 Lipectomy, wedge excision of redundant non abdominal skin and fat that is a direct consequence of significant weight loss, not being a service associated with a service to which item 30165, 30168, 30171, 30176, 30177, 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; and (d) the procedure involves 3 or more excisions

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

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

Facial Surgery Procedures – Eye / Ear

42590 Canthoplasty, medial or lateral

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

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

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

Scar Revision Procedures

45506 Scar, of face or neck, not more than 3 cm in length, revision of, where undertaken in the operating theatre of a hospital, or where performed by a specialist in the practice of his or her specialty

45512 Scar, of face or neck, more than 3 cm in length, revision of, where undertaken in the operating theatre of a hospital, or where performed by a specialist in the practice of his or her specialty

45515 Scar, other than on face or neck, not more than 7 cms in length, revision of, as an independent procedure, where undertaken in the operating theatre of a hospital or where performed by a specialist in the practice of his or her specialty

45518 Scar, other than on face or neck, more than 7 cms in length, revision of, as an independent procedure, where undertaken in the operating theatre of a hospital, or where performed by a specialist in the practice of his or her speciality

Can’t find your Item Number? – There are MANY other Item Numbers on the MBS

Medicare

You can search the MBS by visiting the MBS Online website Or Download the MBS Mobile App – for Apple or Android