Medicare Coverage for Plastic Surgery in Australia

What Plastic Surgery Procedures Are Covered by Medicare?

If you’re considering plastic surgery in Australia, one of the first questions you might have is whether Medicare will cover the procedure. While Medicare does fund some plastic surgery procedures, it’s important to understand that it only applies to surgeries deemed medically necessary. If a procedure is purely cosmetic, you’ll likely have to pay out of pocket.

What Does Medicare Cover?

Medicare is designed to provide financial assistance for medical treatments that are considered essential for your health and wellbeing. This includes some plastic and reconstructive surgeries, but only when they are necessary to improve function, relieve pain, or address medical conditions.

Plastic surgery procedures that Medicare may cover include:

• Reconstructive surgeries after trauma, burns, or cancer treatment
• Procedures that correct congenital conditions, such as cleft lips
• Functional surgeries, like eyelid surgery for vision obstruction or breast reduction to relieve back pain

Medically Necessary vs. Cosmetic Surgery

A key factor in whether Medicare will cover plastic surgery is whether the procedure is deemed medically necessary.

• Medically necessary surgeries: These are procedures required to improve function, correct a deformity, or address a medical condition. For example, a breast reduction may be covered if it alleviates chronic back pain, or an eyelid lift may be approved if sagging skin obstructs your vision.
• Cosmetic surgeries: These are performed purely for aesthetic reasons and are not covered by Medicare. This includes procedures like breast augmentation, facelift, and liposuction (unless there is a medical reason).

How Does Medicare Determine Eligibility?

Medicare eligibility for plastic surgery is assessed based on the Medicare Benefits Schedule (MBS), which outlines specific procedures that qualify for rebates. To be eligible, your procedure must:
✔ Have a corresponding MBS item number
✔ Be supported by a referral from a GP or specialist
✔ Meet Medicare’s criteria for medical necessity

Even if your surgery is listed on the MBS, it doesn’t mean the full cost will be covered. Medicare may cover part of the surgeon’s fee, anaesthesia, and hospital expenses, but there will still be out-of-pocket costs, depending on the procedure and whether you have private health insurance.

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Medicare Benefits Schedule (MBS)

The Medicare Benefits Schedule (MBS) is a list of medical procedures and treatments that Medicare provides rebates for, including certain plastic surgery procedures. Each eligible procedure has an MBS item number, which determines how much Medicare will contribute towards the cost.

If a procedure isn’t listed on the MBS, it means Medicare won’t cover it—unless there are exceptional circumstances where a doctor can make a case for medical necessity.

How the MBS Works

When a procedure is covered under the MBS, Medicare pays a percentage of the scheduled fee set by the government. This fee is not always the same as what a surgeon charges, which means you will still have out-of-pocket expenses.

For plastic surgery procedures:

• Medicare generally covers 75% of the MBS fee for procedures performed in a private hospital
• Medicare covers 100% of the MBS fee if the procedure is done in a public hospital as a public patient (but waiting times may be long)
• If you have private health insurance, it may cover some or all of the gap between the Medicare rebate and the surgeon’s actual fee

Key Plastic Surgery Procedures Listed on the MBS

Some of the plastic and reconstructive surgery procedures included in the MBS are:

• Breast reconstruction after mastectomy
• Abdominoplasty for patients who have lost a significant amount of weight and suffer from medical issues like skin infections
• Eyelid surgery (blepharoplasty) if excess skin is obstructing vision
• Breast reduction for patients experiencing chronic pain or medical complications
• Rhinoplasty if required to correct breathing problems
• Otoplasty (ear surgery) for children with significant ear deformities

Each of these procedures has specific conditions that must be met for Medicare to provide coverage.

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Plastic Surgery Procedures Covered by Medicare

If your surgery meets the medical necessity criteria and is listed on the Medicare Benefits Schedule (MBS), you may be eligible for a rebate to help with some of the costs. Below is a breakdown of the types of plastic surgery that Medicare covers in Australia:

1. Reconstructive Surgery

Reconstructive plastic surgery is performed to restore normal appearance and function after trauma, surgery, disease, or birth defects. Medicare covers several reconstructive procedures, including:

➔ Breast Reconstruction After Mastectomy

If you have undergone a mastectomy due to breast cancer or a high-risk genetic predisposition, Medicare covers breast reconstruction surgery. This includes:
✔ Rebuilding the breast using implants or autologous tissue (flap reconstruction)
✔ Nipple reconstruction
✔ Surgical revisions to improve symmetry
✔ Fat grafting to refine the shape

MBS Item Numbers: 45530, 45531, 45545

💡 Private health insurance may cover additional costs, such as hospital fees, if you are treated in a private hospital.

➔ Skin Cancer Removal and Reconstruction

If you’ve been diagnosed with skin cancer, Medicare will cover surgery to remove the tumour and any necessary reconstructive procedures. This may include:
✔ Excision of malignant skin lesions
✔ Skin grafts or local flaps to close the wound
✔ Reconstructive surgery for facial areas like the nose, lips, or eyelids

MBS Item Numbers: 31000–31340 (depending on the complexity of the procedure)

➔ Post-Trauma or Burns Reconstruction

If you’ve suffered severe trauma or burns, you may need reconstructive surgery to restore movement, function, and appearance. Medicare covers:
✔ Skin grafts for severe burns
✔ Flap surgeries to rebuild damaged areas
✔ Scar revision if scarring causes functional impairment

MBS Item Numbers: 45000–45060

💡 If scarring is purely cosmetic and does not impact function, Medicare may not cover it.

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2. Functional Plastic Surgery

Medicare covers plastic surgery that improves physical function or relieves chronic medical conditions. Here are some procedures that might be eligible:

➔ Breast Reduction for Medical Reasons

If you have excessively large breasts that cause back pain, neck pain, rashes, or other health issues, Medicare may cover a breast reduction (reduction mammoplasty). To qualify:
✔ You must have documented symptoms of chronic pain or functional impairment
✔ Your GP must provide a referral
✔ The surgery must not be performed purely for cosmetic reasons

MBS Item Number: 45523

💡 Private health insurance may cover additional costs, depending on your policy.

➔ Abdominoplasty for Post-Massive Weight Loss

Medicare does not cover tummy tucks for cosmetic reasons. However, it does provide coverage if you’ve lost a significant amount of weight and have medical complications due to excess skin.

You may be eligible if you:
✔ Have lost at least 5 BMI points and maintained the weight loss for six months
✔ Suffer from chronic skin infections, rashes, or sores due to loose skin
✔ Experience functional impairment, such as difficulty exercising or back pain

MBS Item Number: 30177, 30179, 30176, 30175, 30166 

💡 You will need a referral and supporting documentation from a GP and specialist to qualify.

➔ Eyelid Surgery (Blepharoplasty) for Vision Obstruction

If sagging eyelid skin is affecting your vision, you may be eligible for blepharoplasty, a procedure to remove excess eyelid tissue. Medicare covers it if:
✔ The skin droops to the point where it interferes with vision
✔ A doctor has documented visual field obstruction

MBS Item Number: 45617, 45620

💡 If you’re getting eyelid surgery for a more youthful appearance, it won’t be covered.

➔ Rhinoplasty for Breathing Issues

A rhinoplasty (nose surgery) can be covered by Medicare if it’s needed to correct breathing difficulties or repair structural defects from injury or congenital issues.

✔ You must have documented functional impairment (e.g., chronic nasal obstruction)
✔ A specialist must confirm that surgery is necessary

MBS Item Numbers: 45635, 45641

💡 Aesthetic rhinoplasty (purely cosmetic nose reshaping) is not covered.

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3. Congenital and Developmental Conditions

If you were born with a congenital deformity or developmental condition that affects function, Medicare will likely cover corrective plastic surgery.

➔ Cleft Lip and Palate Surgery

Cleft lip and cleft palate repair are fully covered by Medicare as they are essential for speech development, feeding, and facial structure.

MBS Item Numbers: 45677– 52458

➔ Ear Reconstruction (Otoplasty for Microtia or Prominent Ears)

✔ Medicare covers ear reconstruction for children with microtia (underdeveloped ears).
✔ Prominent ear correction (otoplasty) is covered for children under 18 if the condition causes psychological distress.

MBS Item Numbers: 45659

💡 Otoplasty for adults may not be covered unless it corrects a functional issue.

➔ Congenital Breast Conditions

✔ Tubular breast deformity correction – Medicare may cover this if it causes severe asymmetry or functional impairment.
✔ Breast asymmetry correction – If one breast is significantly underdeveloped compared to the other, Medicare may provide coverage.

MBS Item Numbers: 45534, 45060, 45061, 45062, 45524, 45528, 45535

💡 Breast augmentation for aesthetic purposes is not covered.

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Procedures Not Covered by Medicare

While Medicare provides coverage for medically necessary plastic surgery procedures, it does NOT cover surgeries that are purely cosmetic. If a procedure is performed solely to enhance appearance, you will need to pay for it out of pocket. However, there are grey areas where a procedure might be covered if it is deemed medically necessary.

Purely Cosmetic Procedures Not Covered by Medicare

If a procedure does not restore function, correct a medical condition, or alleviate physical symptoms, it is considered cosmetic and therefore ineligible for Medicare rebates.

Some of the cosmetic procedures Medicare does not cover include:

➔ Breast Augmentation (Enlargement with Implants)

• If you want to increase breast size for cosmetic reasons, Medicare will not cover the procedure.
• If implants are used for breast reconstruction after mastectomy or to correct significant congenital asymmetry, then Medicare may provide a rebate.

➔ Facelift (Rhytidectomy)

• A facelift is considered a cosmetic procedure as it is primarily done to reduce signs of ageing.
• If sagging skin is causing a functional problem, such as severe skin laxity after massive weight loss, Medicare might cover part of the cost under specific conditions.

➔ Liposuction

• Liposuction for body contouring and fat reduction is not covered.
• If liposuction is performed for a medical condition, such as lipedema (a painful fat disorder), Medicare may provide partial coverage.

➔ Tummy Tuck (Abdominoplasty) for Cosmetic Purposes

• If you want a flatter, tighter abdomen for aesthetic reasons, Medicare will not cover a tummy tuck.
• If you have excess skin due to massive weight loss that causes medical issues (e.g., chronic skin infections), Medicare may cover the procedure.

➔ Eyelid Surgery (Blepharoplasty) for Cosmetic Reasons

• If you want eyelid surgery to achieve a more youthful look, it is not covered.
• If drooping eyelids obstruct your vision, a Medicare rebate may be available.

➔ Nose Reshaping (Cosmetic Rhinoplasty)

• A rhinoplasty performed for cosmetic reasons is not covered.
• If you require nasal surgery to correct breathing issues or repair damage from trauma, Medicare may help cover the cost.

➔ Ear Surgery (Otoplasty) for Adults

• Otoplasty for prominent ears is only covered for patients under 18 years old.
• If you’re an adult seeking this surgery for aesthetic reasons, you’ll need to fund it yourself.

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The Grey Area – When a Procedure May Be Covered if Medically Necessary

There are situations where a plastic surgery procedure can fall into a grey area – meaning it is usually considered cosmetic but may be covered if there is a clear medical need.

To qualify for Medicare coverage in these situations, the following conditions typically apply:
✔ You must experience functional impairment due to the condition.
✔ A GP and a specialist must assess your condition and confirm medical necessity.
✔ The procedure must have an MBS item number that applies to your situation.

Some examples of procedures in the grey area include:

• Breast implant removal – Covered only if implants have ruptured, caused capsular contracture, or led to chronic pain and you meet the criteria.
• Abdominoplasty – Covered only if you have significant medical issues after massive weight loss or split tummy muscles (diastasis recti) after pregnancy and meet the strict criteria.
• Eyelid surgery (blepharoplasty) – Covered if sagging skin obstructs your vision and you meet the criteria.

If you believe your surgery falls into this grey area, you’ll need strong medical documentation to support your case.

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How to Check if Your Surgery Is Covered by Australian Medicare

If you’re considering Australian plastic surgery and want to know whether Medicare will cover it, there are several steps you can take.

Consulting with a Specialist Plastic Surgeon

The best place to start is by speaking to a plastic surgeon who is experienced with Medicare-covered procedures. They can:
✔ Assess whether your procedure meets Medicare’s medical necessity criteria.
✔ Provide you with the relevant MBS item number.
✔ Advise on whether private health insurance may help cover extra costs.

💡 Make sure you choose a Specialist Plastic Surgeon (FRACS-qualified) who understands Medicare’s requirements.

Getting a Referral from a GP

In most cases, you’ll need a referral from a GP or specialist before Medicare will consider covering your surgery. Your GP will:
✔ Assess your condition and determine if you meet Medicare’s criteria.
✔ Write a referral to a plastic surgeon if medical necessity is established.
✔ Include relevant medical history, symptoms, and past treatments.

💡 Referrals are often required for Medicare rebates, even if the procedure has an MBS item number.

Finding the Right MBS Item Number

The Medicare Benefits Schedule (MBS) lists all the procedures that qualify for rebates. To check if your surgery is covered:
✔ Visit the MBS website (www.mbsonline.gov.au).
✔ Search for your procedure or ask your plastic surgeon for the correct item number.
✔ Check the eligibility criteria associated with that item number.

Medicare Rebates and Out-of-Pocket Costs

Even if Medicare covers your procedure, it won’t necessarily be free. You may still have out-of-pocket costs, depending on the surgeon’s fees and hospital charges.

✔ Medicare covers 75% of the MBS fee if the surgery is performed in a private hospital.
✔ Medicare covers 100% of the MBS fee if the surgery is performed in a public hospital as a public patient.
✔ Surgeons often charge more than the MBS fee, leading to a gap payment.

💡 Check with your plastic surgeon whether there will be any extra costs beyond what Medicare covers.

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When Private Health Insurance May Help

If you have private health insurance, it may help cover additional costs, such as:
✔ Surgeon’s fees beyond the Medicare rebate
✔ Private hospital costs (accommodation, theatre fees)
✔ Anaesthetist fees

💡 Check with your health fund to see if your policy includes plastic surgery procedures.

Payment Plans and Financing Options

If Medicare or private health insurance doesn’t cover all costs, you may need to explore other payment options, such as:
✔ Interest-free payment plans – Some clinics offer flexible plans.
✔ Medical loans – Specialised lenders offer loans for elective surgery.
✔ Superannuation withdrawal – In extreme cases, you may be able to access your super early for medical treatment.

💡 Before choosing a financing option, make sure you understand all costs and interest rates involved.

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How to Apply for Medicare Coverage

Applying for Medicare coverage for plastic surgery requires careful preparation, as Medicare will only cover procedures deemed medically necessary. To ensure your application is successful, you must provide the correct documentation, supporting medical evidence, and, in some cases, obtain pre-approval before surgery.

Required Documentation (Referrals, Medical Reports, Photos)

To claim Medicare coverage for plastic surgery, you must submit the necessary paperwork. The exact requirements vary depending on the procedure, but generally, you will need:

1. Referral from a GP or Specialist

Most Medicare-covered plastic surgeries require a referral from a General Practitioner (GP) or another specialist. This document confirms that your procedure is medically necessary and provides Medicare with:
✔ A summary of your medical history
✔ Details about the symptoms or conditions that justify surgery
✔ Evidence of previous treatments (if applicable)

💡 A GP referral is valid for 12 months, while a referral from a specialist is valid for only three months.

2. Specialist Medical Reports

Your plastic surgeon will prepare a detailed report outlining why the procedure is necessary. Medicare uses this information to determine whether you qualify for a rebate. The report typically includes:
✔ An explanation of how the condition affects your daily life
✔ Medical evidence demonstrating pain, discomfort, or functional impairment
✔ A history of non-surgical treatments tried before considering surgery

For example, if you are applying for breast reduction, the report may highlight:

• Chronic back, neck, or shoulder pain
• Recurring skin infections caused by excessive breast weight
• The failure of non-surgical treatments like physiotherapy or supportive garments

💡 If the surgery is for post-trauma reconstruction (e.g., after skin cancer removal or burns), your surgeon may also include pathology reports or hospital records.

3. Photographic Evidence (If Required)

For some procedures, Medicare requires photographic evidence to assess whether the surgery meets medical necessity criteria. Your plastic surgeon may need to submit clinical photos to Medicare, along with your application.

Examples of surgeries requiring photo documentation:
✔ Eyelid surgery (blepharoplasty) – Proof of vision obstruction due to sagging skin
✔ Breast reduction – Evidence of breast-related health complications
✔ Abdominoplasty – Documentation of excess skin causing chronic infections after major weight loss

💡 The photos must be taken by a medical professional and submitted alongside your claim.

4. Additional Test Results (If Needed)

In some cases, Medicare may require additional medical tests to verify eligibility for coverage. These tests may include:
✔ Visual field tests (for eyelid surgery) to confirm vision obstruction
✔ Breathing assessments (for rhinoplasty) to prove functional nasal obstruction
✔ MRI scans or X-rays (for breast reduction) to document spinal strain

If your surgery requires extra evidence, these tests must be completed before submitting your application.

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Getting Pre-Approval for Specific Surgeries

Some plastic surgery procedures require pre-approval from Medicare before the surgery can proceed. This process ensures that the procedure meets strict eligibility criteria and reduces the risk of claims being rejected later.

➔ When is Pre-Approval Required?

You may need Medicare pre-approval if:
✔ The procedure is commonly performed for cosmetic reasons, but you need it for medical reasons (e.g., abdominoplasty after massive weight loss)
✔ Your surgery has specific eligibility requirements that require verification (e.g., eyelid surgery for vision obstruction)
✔ The MBS guidelines state that prior approval is necessary for a rebate

Your plastic surgeon will inform you if your procedure requires pre-approval.

➔ How to Apply for Pre-Approval

If your surgery requires Medicare pre-approval, your plastic surgeon will submit an application on your behalf. This process typically includes:

🔹 Step 1: Your plastic surgeon prepares and submits an application to Medicare, including:

• Your GP referral
• A detailed specialist report explaining why the procedure is medically necessary
• Photographic evidence or medical test results, if required
• The MBS item number(s) relevant to your surgery

🔹 Step 2: Medicare reviews the application, which can take several weeks. If additional information is needed, they may request further documentation.

🔹 Step 3: If Medicare approves the request, you’ll receive confirmation that the procedure is eligible for a rebate. If denied, you may be able to submit additional supporting evidence or appeal the decision.

💡 Pre-approval does not mean Medicare will cover 100% of the costs. You may still have out-of-pocket expenses, depending on your plastic surgeon’s fees and hospital charges.

FAQs About Medicare and Plastic Surgery

Further Reading about Procedures Covered by Medicare

Read these Blogs for more information about Australian Medicare Coverage for Plastic Surgery

• Read Medicare for Breasts with Congenital Deformities
• Read Does Medicare Cover my Breast Reduction Surgery?
• Read Does Medicare Cover My Tummy Tuck?
• Read Does Medicare Cover My Top Surgery?
• Read Does Medicare cover my Labiaplasty?
• Read Does Medicare cover my Breast Augmentation for congenital concerns?

Read about the Prices and Costs of Plastic Surgery in Australia

• Cost of a Mummy Makeover Surgery in Australia
• Cost of a Tummy Tuck Surgery in Australia
• Cost of Labiaplasty in Australia
• Cost of Fat Transfer to Breasts Surgery in Australia