Many people want to know if Medicare will cover plastic surgery.
Medicare announced major improvements in the Medicare Benefits Schedule (MBS) to cosmetic surgery item numbers effective from November 1, 2018. For more information. With some major differences, new Medicare Benefits Schedule codes were created. In terms of redefining each category, adjustments have also occurred to Health Fund Policy Classifications and Private Health Benefits for surgery.
Medicare will cover what is called critical reconstructive surgery and procedures specified in the Medicare Benefits Schedule (MBS) that have related Medicare item numbers.
Your surgeon will be able to help you understand if your treatment is covered by Medicare, so please refer to the Medicare Benefits Schedule for clear reference.
Refer to the Medicare Benefits if you want to look up a specific type of surgery to get more information or to look at the various procedures and their numbered item.
Cosmetic vs. Medical Surgery: A significant difference
It will be useful to distinguish between two forms of plastic surgery before we begin our exploration:
Surgery that is solely cosmetic has never been covered or qualified for a Medicare rebate. That didn’t shift. What has changed is the way the MBS categorizes different surgeries and the eligibility requirements. Any surgeries were excluded from the list entirely.
- Cosmetic surgery – a procedure carried out for purely esthetic purposes ( e.g. rhinoplasty to correct a lump on the nose bridge).
- Medical plastic surgery – surgery needed by an injury or to enhance a malformed body part’s function (e.g. rhinoplasty to restore breathing function after a car accident).
What is covered and not covered by Medicare?
Medicare is the cornerstone of the health care system in Australia which covers a lot of healthcare expenses. You can be treated in a public hospital, free of charge, as a public patient under Medicare. Any or all the expenses of seeing a GP or doctor outside the hospital, including some pharmaceuticals, will also be covered by Medicare.
Medicare provides benefits for:
- Doctors’ consulting fees, including specialists;
- Doctor’s tests and evaluations required for the treatment of diseases, such as x-rays and pathology tests;
- Eye examinations by optometrists;
- Most physicians have conducted surgical and other clinical procedures;
- Some surgical procedures that have been carried out by licensed dentists;
- Under the Cleft Lip and Palate Scheme, unique items;
- Under the Enhanced Primary Care (EPC) scheme, unique items; and
- Relevant products as part of the Chronic Disease Treatment Strategy for allied health services.
Medicare does not cover:
- Life insurance, superannuation or membership examinations for which someone else is liable (such as a benefits insurer, employer or government authority);
- Services for ambulances;
- Most dental tests and therapy;
- Most facilities related to physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic, podiatry or psychology;
- Acupuncture (unless part of a consultation with a doctor);
- Contact lenses and glasses;
- Some equipment and hearing aids; and
- Nursing house.
Does Medicare pay for skin removal surgery?
Medicare covers skin removal if you are suffering from excess skin following weight loss. Excess skin removal may not be the step of weight loss you expected, but insurance may help pay for the operation. You need to comply with any of the following for approval: Healthy weight for 6 months prior to surgery.
For approval, you need to meet all the following:
- Stable weight for 6 months prior to service
- A disease of the skin that affects the skin’s health
- Excess skin that affects everyday movement
- At least 5 points of BMI must drop
How can I get a tummy tuck with Medicare?
It’s a big operation if you’re thinking of abdominoplasty, and it’s not acceptable for everyone. The cost of plastic surgery is not covered by Medicare, and often neither does private health insurance. However, part of the expenses could be protected if abdominoplasty is performed for reconstructive purposes.
Before a patient leaves our facility, a patient may obtain some advice on their aftercare, which could include the use of some drugs as well as wound care. When in doubt about your aftercare, we always advise patients to contact Dr Mark Duncan-Smith of CosmedicWest or call us at (08) 9228 2188 for further information.
Firouzbakht, Peter K. B.S.; Israel, Jacqueline S. M.D.; Chen, Jenny T. M.D.; Rao, Venkat K. M.D., M.B.A. Medicare for the Plastic and Reconstructive Surgeon, Plastic and Reconstructive Surgery: August 2018 – Volume 142 – Issue 2 – p 568-576 doi: https://doi.org/10.1097/PRS.0000000000004587
Melissa M. Farmer, et al. Linking Medicare and National Survey Data. Annals of Internal Medicine 1997;127:691-695. [Epub ahead of print 15 October 1997]. doi:https://doi.org/10.7326/0003-4819-127-8_Part_2-199710151-00051
David, G., Saynisch, P., Acevedo‐Perez, V. and Neuman, M.D. (2012), AFFORDING TO WAIT: MEDICARE INITIATION AND THE USE OF HEALTH CARE. Health Econ., 21: 1030-1036. https://doi.org/10.1002/hec.1772
Susan Bartlett Foote; Why Medicare Cannot Promulgate a National Coverage Rule: A Case of Regula Mortis. J Health Polit Policy Law 1 October 2002; 27 (5): 707–730. doi: https://doi.org/10.1215/03616878-27-5-707