Medicare was created in 1984 to ensure all Australians have access to essential care.

Almost immediately, questions arose as to the definition of ‘essential care.’ In 2018, new Medicare Benefits Schedule codes were established with some significant differences. Changes have also occurred to Health Fund Policy Classifications and Private Health Coverage for surgery in terms of redefining each category.

Needless to say, the newest iteration of the Medicare Benefits Schedule (MBS) has left many patients somewhat dazed and confused regarding the cost of surgery in Australia. Let’s see if Team Costhetics can’t clear up at least some of the confusion.

Cosmetic vs. Medical Surgery: An Important Difference

Before we begin our exploration, it would be valuable to differentiate between two types of plastic surgeries:

• Cosmetic plastic surgery – surgery that is performed for purely aesthetic reasons (e.g. rhinoplasty to correct a bump on the bridge of the nose).
• Medical plastic surgery – surgery that is necessitated by an injury or to improve the function of a malformed body part (e.g. rhinoplasty to restore breathing function after a car accident).

Surgery that is purely cosmetic has never been covered or eligible for a rebate from Medicare. That has not changed. What has changed is the way the MBS classifies various surgeries and the criteria for eligibility. Some surgeries have been removed entirely from the list.

Other changes put new responsibilities on patients…

New Responsibilities for Plastic Surgery Patients

It is now necessary to provide full payment for your surgery upfront. When, and only when your procedure is complete can you apply for any Medicare and Health Fund rebates. Additionally, the new regulations narrow the scope of eligible procedures.

To meet eligibility, you may be asked to provide:

• Documentation from your doctor
• Additional pre-surgery test results or evaluations
• Photographic evidence

The Australian Society of Plastic Surgeons posted a release exploring the effect of Medicare changes on patients. They report that the greatest impact will be felt on several of Australia’s most popular plastic surgeries.

Does Medicare Cover Tummy Tuck Surgery (Abdominoplasty) in Australia?

Abdominoplasty, also known as a tummy tuck, is the go-to surgery for individuals struggling to rid themselves of body fat and excess skin that is unresponsive to diet or exercise.

In 2019, the cost of a tummy tuck in Australia ranged from $15,000 to $29,000, depending on factors including the amount of skin to be removed, surgeon’s fees, where your doctor is located in Australia, and the specific type of abdominal body contouring to be performed:

• Mini Tummy Tuck – removes baggy, excess skin and fatty tissue from the lower stomach area without manipulation of the abdominal muscles.
• Traditional Tummy Tuck – In this approach, abdominal muscles that have become loose or separated are repaired, while excess skin and tissue are removed.

Both of these surgeries are considered cosmetic in nature and are not covered by Medicare.

• Extended Tummy Tuck – This surgery is offered exclusively to patients who have lost a significant amount of weight, either naturally or with the help of bariatric surgery. The procedure goes beyond a traditional tummy tuck, literally, to address excess skin and tissue on the thighs, hips, and back. At the same time, loose abdominal, flank and back muscles can also be corrected.

An extended tummy tuck is considered restorative surgery and is covered by Medicare if you’ve had significant weight loss to the tune of 5 BMI points or more, which equates to 15kg’s of weight loss. The medicare item code is 30177 for tummy tuck surgery (also called lipectomy) due to weight loss. Although the medicare rebate is relatively small, qualifying for the item code often means that your private health insurance will pay for some or even all of your hospital fees which is a major component of the cost of the surgery. In 2019 there were 2,727 Australian women had a tummy tuck and qualified for the medicare item code 30177. Item codes 30165, 30168, 30171 are also sometimes used for tummy tuck related surgeries, but less commonly so.

Does Medicare Cover Eyelift Surgery in Australia?

Droopy eyelids, crow’s feet, and dark bags are problems related to an ageing face. So is the inability to read or see correctly because loose skin is obscuring your vision. As with tummy tucks, eyelift surgery Medicare coverage depends on the type procedure you are having and why:

• Cosmetic upper eyelid blepharoplasty – During this surgery, fat bulges over the eye are moved, along with excess skin along the upper eyelids. The surgeon also firms and tightens inelastic skin and lax muscles. The results are a more youthful, wide-awake appearance, with fewer fine lines and wrinkles. This procedure is not covered by Medicare.
• Cosmetic lower eyelid blepharoplasty – Lower eyelid skin is delicate, thin, and at the mercy of UV rays, gravity, and genetics. A lower eyelift addresses the damage by removing excess skin and fat and repositioning the remaining skin to create a more vibrant-looking eye. In some instances, it may be coupled with laser resurfacing or a chemical peel to further tighten skin. This procedure is not covered by Medicare.
• Cosmetic brow lift – Commonly referred to as forehead lift, this surgery is used to remove sagging, excess skin above your eyebrows and reposition the underlying tissues and muscles. The benefits include raising eyebrows and gently lifting eyelids. It may be performed endoscopically or using other surgical techniques. This procedure is not covered by Medicare.
• Ptosis Repair Surgery – This is a specific type of upper eyelid blepharoplasty for people whose drooping eyelids are impeding their vision. The surgery focuses on manipulating and strengthening eyelid muscles too weak to do their job. Ptosis can be repaired with or without an incision over the eyelid. An external approach allows the surgeon to trim away excess fat and skin for a more aesthetically pleasing outcome. This procedure is considered a medical necessity and is covered by Medicare.

Does Medicare Cover Breast Surgery in Australia

We do love breast enhancement here in ‘Straya. They are a perennial entry in every year’s Hottest Cosmetic Surgery in Australia list. Among the procedures available:

• Cosmetic Breast Augmentation – In this surgery, breast implants are placed over or under the chest muscle, producing a more flattering contour. The implants are made in a variety of sizes, shapes and textures to help women achieve the aesthetic they are seeking. This surgery is not covered by Medicare.

• Cosmetic Breast Lift – Referred to as mastopexy by surgeons, this operation raises the breasts by removing excess skin and tightening surrounding tissue. Surgeons may also raise the nipple and areola into a more forward position. Women with overly large areolae can have them reduced during their procedure. This surgery is not covered by Medicare.

• Reconstructive Breast Surgery – This is an umbrella title for the surgical rebuilding of the breasts. Reconstructive surgery can be accomplished using prosthetic breast implants, autologous fat tissue, or a combination of the two. It is most commonly used on women who have undergone surgery for breast cancer. Reconstructive breast surgery is covered by Medicare.

• Cosmetic Breast Reduction Surgery (Mammoplasty) – Excess breast fat, glandular tissue and skin can give individuals irregular contours that make them unhappy. Feeling top heavy and out of proportion, people who have oversized breasts may have trouble finding clothes. Others may feel a sense of social stigma. Though it can be life-changing, cosmetic breast reduction surgery is not covered by Medicare.

• Macromastia Surgery (Breast Reduction) – The medical condition known as macromastia is characterised by breasts that are disproportionately large and creating physical discomfort such as under-bra rashes, and back, neck, and shoulder pain. In this procedure, the doctor makes an incision around the areola and under the fold of each breast. (Thanks to advances in techniques, this surgery can now be performed without increased risk to nipple-areolar complex viability. Next, excess breast tissue and skin can be removed and the breast shape is corrected. A final lifting of the muscles also helps relieve discomfort. This procedure is covered by Medicare, as is male breast reduction surgery.

It should be noted that while providing medical benefits, many surgeries may be used to provide cosmetic benefits to the patient as well as medical benefits. Two-for-one.

Do Your Research, Then Ask Your Surgeon

We consider ourselves to be pretty bright cookies at Costhetics, but even we were stymied by some of the intricacies of Medicare reimbursement. If you meet the Medicare criteria for a procedure, you may still be liable for some out of pocket costs:

• Anaesthetist’s fee
• Hospital fees
• Post-surgical garments
• Surgeon’s fee

Plastic surgeons may not be able to help you navigate the Medicare coding system themselves, but most practices have a team member who is crackerjack at deciphering the code of Medicare reimbursement for surgery. Don’t be shy. Ask for help.

Better health and beauty through knowledge. That’s the Costhetics Way.