One of the most common things people ask when thinking about or planning a plastic or cosmetic surgery procedure is “Will I be covered by Medicare?” This is not an easy question to answer as there are so many variables and can vary from patient to patient. However, generally, Medicare won’t cover purely cosmetic procedures. We take a closer look at what they do and don’t cover.
Does Medicare cover Plastic Surgery?
Medicare will cover some procedures. They are generally for reconstructive and what is deemed as essential surgery. If your procedure is listed in the Medicare Benefits Schedule (MBA) then you have a better chance of being covered:
Breast augmentation for cosmetic purposes only is not covered. However, there are the following exceptions.
(i) Breasts with asymmetry larger than 10% (one breast is 10% larger than the other);
(ii) Breast Ptosis (drooping or sagging breasts) – following pregnancy and lactation (not less than a year or more than 7 years after the end of pregnancy);
(iii) Malformation of breast tissue;
(iv) Disease or trauma of the breast (not caused by previous cosmetic surgery);
(v) Following a mastectomy;
(vi) Nipple or Areola Reconstruction;
(vii) Breast prosthesis (and replacement) – a silicone mould resembling the shape and weight of the breast.
(viii) Breast reduction – this is generally not covered, however your surgeon may apply on your behalf if you have proven physical (medical) and mental issues resulting from your “condition”.
The schedule notes that no breast surgery will be performed purely for cosmetic purposes, or to correct any previous cosmetic surgery.
Rhinoplasty is listed as being covered where the surgery is being performed to:
(i) Correct nasal obstruction;
(ii) Post-traumatic deformity (except where it is a result of previous elective cosmetic surgery);
(iii) Correction of significant developmental deformity;
(iv) Correction of all bony and cartilaginous elements of the external nose.
Abdominoplasty is only covered for reconstruction after surgery or trauma. Basically, Medicare will only consider covering a procedure if it is deemed absolutely medically necessary and this includes abdominoplasty. When you are consulting with a plastic surgeon regarding your procedure, we suggest you ask them if you might be considered eligible (such as massive weight loss patients with a huge amount of excess skin that is affecting your movement and quality of life).
Gastric Band Surgery
Anyone with clinical morbid obesity may be covered for gastric band surgery. Your doctor or surgeon will be able to identify if you are eligible.
Is Cosmetic Surgery Covered By Medicare?
Cosmetic Surgery is not covered by Medicare. It is very clear that any surgery not identified as “necessary” or for medical purposes will not be considered. This means anything labeled as being for cosmetic purposes will not be claimable.
However, a practitioner may apply to the Department of Human Services on behalf of a patient for any proposed surgery. They need to identify that surgery is necessary for medical reasons, and may have to provide photos and clinical details to convince the Department that it is essential surgery for the wellbeing of the patient.
For more information on what private insurance covers when it comes to Plastic and Cosmetic Surgery read here.
If you wish to look up a particular type of surgery to get more information or to look at the different surgeries and their item numbers, refer to the Medicare Benefits Schedule at http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home.
Original blog post 4/2/2015