Medicare, Health Insurance and Plastic Surgery – What are you covered for?

There are so many variables when it comes to plastic surgery, health insurance and what plastic surgery procedures are eligible for Medicare rebates. We spoke with Dr Rohit Kumar of Sydney Cosmetic Sanctuary to help us understand, in everyday language, what the go is with Medicare item numbers and private health insurance. Here’s what he had to say.

PSH: If a patient has private cover and there’s an item number, will they be eligible for the hospital rebate?

Dr Kumar: The first thing is, does the patient have private health insurance? That may or may not help. They may be eligible for a rebate on their hospital admission whether as a day surgery patient or if they stay longer but this will depend on their level of cover. Their cover might cover them 80%, it may cover them 100%, it’s varied, but if they have good tier of cover and if the procedure attracts an item number, then there’s a very good chance that the hospital theatre and equipment fees, the overnight bed fees, part of the anesthetic fee and part of the surgeon’s fee will all be rebateable to them. This can be a reasonably good saving.

It’s always worth finding out if a patient has private cover. If they don’t and their procedure has an item number,and it is performed in a private hospital then Medicare is still going to give them something back, but this is quite limited and is always better with Private Health Insurance.

PSH: Could a cosmetic procedure have an item number if a similar procedure has a reconstruction number?

Dr Kumar: No. Once you’ve performed a procedure purely for cosmetic reasons, it doesn’t have an item number. Breast augmentation for example doesn’t unless it is being done for a patient who has had surgery following breast cancer.

If you run into a complication however, there may be an item number for the particular treatment of the complication irrespective of whether the procedure was done for cosmetic reasons or not.

For example, you may have had an abdominoplasty (tummy tuck). There is no item number for this if it is done outside of significant weight loss.Therefore, it is deemed a “cosmetic procedure”. If you have a complication such as a wound breakdown and need surgery to fix it then depending on your individual circumstances, there may be appropriate item numbers that cover this surgery. In the private system you might not cover the full cost of the physical operation due to other associated out of pocket fees, but if the patient is staying in the hospital as a result of the surgery, for one or two days, then this should be covered. The overall saving can be a lot.

A procedure such as this may be accessible through the public system but this will vary on a case by case basis and how urgent it is.

Dr Rohit Kumar - Medicare and plastic surgery
Dr Rohit Kumar

PSH: Is there much of a gap between the rebate and the surgeon’s fee?

Dr Kumar: All things considered, there will probably still be a few thousand dollars out of pocket. But it’s better than adding multiple thousands in hospital fees.

PSH: With all the changes regarding Medicare and Abdominoplasty, can you clarify when a patient is eligible for a tummy tuck? Is there no circumstance where women are eligible for a tummy tuck after having children?

Dr Kumar: The rules to allow patients requesting an abdominoplasty ( tummy tuck) to be eligible for private health cover or a medicare rebate have changed. There are now some very specific requirements that need to be met in order to qualify.

The item code commonly used is 30177.

In order to qualify for this the following needs to occur:

(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
If it can be shown that the patient has met the above criteria then they should be able to get a rebate on their lipectomy/abdominoplasty surgery. Unfortunately other then meeting the above criteria, there are no specific circumstances where women can have a rebatable abdominoplasty procedure.

PSH: If a massive weight loss patient is eligible for an abdominoplasty, what will Medicare help with and how much will the patient have covered?

In the same way as mentioned above, if the patient meets the criteria then they will have a rebatable procedure. It is extremely rare for these procedures to be done in the public system except in very special cases so the vast majority will be done in the private system. If the patient is uninsured ( self funding) then they will get a small amount back from Medicare and the private hospital fees won’t attract the GST but they will still need to pay the charges themselves. If they have private insurance then other than their individual excess the cost of the hospital stay should all be covered as well as a rebate towards the anaesthetists fee and also a rebate on the procedure that will then reduce the overall surgeons fees and therefore, out of pocket expenses

PSH: Do any other skin removal procedures after massive weight loss attract an item number through Medicare? Eg. brachioplasty, thigh lift, etc.

In the right circumstances, following massive weight loss procedures such as arm lifts (brachioplasty), breast reshaping (reduction/lift) thigh lifts, buttock lifts can all attract a rebatable item number

PSH: Are breast reconstructions after cancer covered by Medicare?

Yes breast reconstructions are covered by Medicare. They can and are offered in the public hospital systems of various hospitals and if the patient is willing to be placed on a waiting list then they can have the procedure at no cost to them.

PSH: What about breast reductions where the breasts are causing physical problems and issues?

Breast reductions are addressed on a case by case basis. Occasionally due to age, symptoms or psychology it will be possible to have a breast reduction in the public system. For the vast majority of patients though, this is a procedure that has an item number but is done in the private system.

PSH: What about tubular breasts or any other breast conditions?

Breast cancer reconstruction and congenital breast conditions are the main breast conditions that can be done in the public hospital system. Other then this the vast majority of procedures are performed in a private hospital

PSH: Can you explain when Rhinoplasty attracts a Medicare item number? It’s obviously not just for cosmetic/aesthetic purposes, but need to be for breathing issues, etc.?

If the patient has a functional issue (eg. breathing problems or a physical obstruction), there has been associated trauma or the problem is congenital then a patient may be able to have a rhinoplasty in the public system. It is important to delineate that this rhinoplasty is for function and to return the nose to the way it looked pre injury. It is not for patients wishing to enhance or change their nose.

PSH: How much control does a plastic surgeon have over whether the patient is eligible for a Medicare item number or not? Can one plastic surgeon make a different decision as to whether a patient needs the surgery as opposed to it only being “cosmetic” than another plastic surgeon?

The item numbers have been determined at the Health Department level. The interpretation of whether a patient’s particular condition fits into the appropriate item number criteria is determined by the individual surgeon. It is important to note that should a surgeon decide that a patient is eligible for a particular item number (especially ones that may be open to interpretation) then they need to have enough evidence and documentation (photos, measurements, communication with GP’s, etc) to ensure that should they be audited they can justify their decision. If this can not be done then there can be significant repercussions to the surgeon and patient so it is essential that patients see ethical and reputable surgeons to ensure that they get their maximum benefit but also so that they don’t end up further out of pocket then they originally expected. There has to be a genuine medical need to perform the procedure in order for it to qualify for an item number.

If you have any further questions, just ask them in the comments below and Dr Kumar will try to answer them for you.

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