Medicare item numbers are used to identify specific medical services and procedures that are eligible for rebates from Medicare, (the Australian government’s healthcare program).
If you have a valid medical referral and meet the strict criteria for a Medicare item number, you may be eligible for a Medicare rebate and a subsidy from your private health insurance fund.
Medicare will not cover purely cosmetic surgery. However, some breast, body, nose, and face surgery are considered medically necessary and you can qualify for a rebate if you have a valid medical reason.
Download your Free Guide to Medicare rebates for plastic surgery
A 2023 Guide to Medicare and Health Insurance Rebates
Will medicare cover part of your surgery under the Medical Benefits Scheme?
The answer to this question can often be confusing because it will vary depending on the patient and the procedure required.
Find out in this guide which procedures include a rebate.
What is a valid medical reason for plastic surgery?
A valid medical reason for plastic surgery is any condition or concern that significantly affects a person’s physical health, functional abilities, or emotional well-being. Plastic surgery is often performed to address medical issues, correct congenital deformities, repair injuries, or improve a patient’s quality of life. Some common valid medical reasons for plastic surgery include:
Correcting congenital anomalies
Plastic surgery may help correct birth defects such as cleft lip and palate, craniosynostosis, or other congenital abnormalities that can impact health and development.
Reconstructive surgery after trauma or injury
Plastic surgery can often help repair injuries that are a result of either accidents, burns, or other traumas. Reconstruction aims to restore not only function and appearance, but also a patients self-perception.
Correcting structural issues affecting breathing
Both Rhinoplasty and septoplasty can help address nasal abnormalities that cause breathing difficulties or sleep apnea.
Treatment of skin cancer
Skin cancer removal often requires reconstructive surgery to restore the affected area’s appearance and function.
Post-mastectomy breast reconstruction
After a mastectomy due to breast cancer, breast reconstruction can help restore a woman’s sense of femininity and self-esteem.
Hand surgery
Plastic surgery on the hands can correct deformities, improve function, and alleviate pain caused by conditions like carpal tunnel syndrome or Dupuytren’s contracture.
Weight loss surgery
After significant weight loss, body contouring procedures can remove excess skin and tissue, improving mobility and preventing skin-related health issues.
Gender-affirming surgeries
For transgender individuals, plastic surgery procedures like breast augmentation, chest masculinization, or genital reconstruction can help align their physical appearance with their gender identity.
It is essential for patients to discuss their specific medical concerns with a qualified plastic surgeon to not only determine the most appropriate treatment plan but to also ensure that the surgery is performed for valid medical reasons.
For other surgical procedures, the best way to find out if you can get a rebate from Medicare is to consult 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 see a specialist. In order to be eligible for cover by Medicare, you need to ensure that the specialist you get a referral to is an accredited surgeon.
It’s important to note that plastic surgeons and cosmetic surgeons are different doctors. Medicare will only cover you if you see a fully-trained and qualified RACS surgeon.
Will Medicare cover my procedure?
The Medicare Benefits Schedule (MBS) is searchable online and is a great resource if you’re doing some preliminary research about your chosen procedure. You can also find out the criteria and the Medicare rebate. Visit the MBS Medicare website.
Popular Medicare Item Numbers
Surgeon consultations
104 First consultation.
Professional attendance at consulting rooms or hospital 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
A Guide to Your First Plastic Surgery Consultation
What should you expect when you meet your Plastic Surgeon?
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, 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.)
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 Caanthoplasty, medial or lateral (Anaes.) (Assist.)
- 42866 Entropion or Tarsal Entropion, 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 a 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 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 item45617 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.)
Dr Broughton Snell
MED0001190266
Specialist Plastic Surgeon in Melbourne Victoria
Dr Snell is a Melbourne Plastic, Reconstructive and Cosmetic Surgeon providing a wide range of services from skin cancer and hand surgery to cosmetic surgery for the face, nose, breast and body.
Mr Snell is able to care for both public and private patients in Melbourne hospitals.
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