Considering plastic or reconstructive surgery? It’s important to understand how Medicare and private health insurance work when it comes to funding your procedure. At Dr Kumar’s practice, we often receive questions from patients about whether their desired surgery is eligible for a Medicare rebate, and how that impacts their total costs.
Here, we break down everything you need to know to help you make an informed decision.
Which Plastic Surgery Procedures Are Eligible for Medicare Rebates?
Medicare only covers procedures that are deemed medically necessary. Cosmetic procedures performed purely for aesthetic reasons are not eligible for rebates.
If a procedure corrects a congenital defect, trauma, or a condition that significantly impairs function or causes persistent pain or health issues, it may be considered for a Medicare rebate —provided it is listed under the Medicare Benefits Schedule (MBS).
Examples of Commonly Rebated Procedures at Dr Kumar’s Clinic:
| Procedure | Eligibility Criteria | MBS Item |
|---|---|---|
| Breast Reduction | Must be for relief of neck/back pain, skin irritation, or posture issues due to large breasts. | 45523 |
| Breast Reconstruction | Following mastectomy for breast cancer or injury. | 45585 – 45588 |
| Abdominoplasty (Tummy Tuck) | For patients with significant skin laxity and/or muscle separation (rectus diastasis) post-pregnancy or weight loss. Medical criteria must be met. | 30175 |
| Blepharoplasty (Eyelid Surgery) | Must be for functional issues like obstructed vision, not cosmetic enhancement. Visual field testing and photographic evidence required. | 45617 |
| Post-Massive Weight Loss Body Contouring | Requires documented history of massive weight loss (usually 5+ BMI points), skin chafing, and hygiene issues. | 30177–30179 |
How Is Eligibility Determined?
Eligibility isn’t automatically granted. To claim a Medicare rebate:
1. Medical Necessity Must Be Proven
Your condition must significantly affect your physical health or function.
2. The Procedure Must Have an MBS Item Number
Only procedures listed in the MBS are eligible.
3. Supporting Documentation Is Required
This may include:
- GP referral letter
- Medical imaging (if relevant)
- High-quality clinical photographs
- Test results or specialist assessments
Dr Kumar and his team will assist in assessing your case and compiling the required documentation to determine if you qualify for a rebate.
Understanding Private Health Insurance and Gaps in Coverage
If your surgery has an MBS item number and you hold the appropriate level of private health insurance, your insurer may help cover hospital-related costs such as:
- Theatre fees
- Private hospital accommodation
- Anaesthetist fees (partially)
- Assistants’ fees (if applicable)
However, it is very important to understand:
A Medicare rebate and/or private health insurance does NOT mean your procedure is completely covered.
You may still face out-of-pocket expenses such as:
- Surgeon’s fee (above the Medicare/health fund scheduled fee)
- Anaesthetist gap payments
- Surgical garments
- Consultations and follow-up appointments
- Any additional procedures not covered
Dr Kumar’s team will always provide a full financial breakdown (Informed Financial Consent) before your surgery so you’re aware of all costs upfront.
Frequently Asked Questions
Q: Will I get a Medicare rebate for a cosmetic breast augmentation?
A: No. Cosmetic procedures such as breast enlargement without medical indication (e.g., congenital deformity or post-mastectomy reconstruction) are not eligible for Medicare rebates.
Q: I’ve lost significant weight – will my body contouring be covered?
A: Possibly. If you meet criteria such as a minimum 5 BMI point loss, stable weight for 6 months, and experience hygiene or skin conditions due to excess skin, you may be eligible under specific MBS items. A consultation with Dr Kumar is necessary for assessment.
Q: Can Dr Kumar help me determine my eligibility?
A: Yes. Dr Kumar has extensive experience navigating the MBS and will conduct a comprehensive consultation to assess your eligibility and advise on documentation and referral pathways.
Ready to Find Out if You’re Eligible?
Book a consultation with Dr Kumar to explore your options. Our team will guide you through:
- MBS eligibility
- Health insurance coordination
- Expected rebates and out-of-pocket fees
Clinics in Sydney, Westmead, Penrith and Orange | Call: 1300 267 726 or www.drkumar.com.au to enquire online.
Helpful Resources
- [Medicare Benefits Schedule (MBS)](https://www.mbsonline.gov.au/)
- [Australian Society of Plastic Surgeons – Medicare Information](https://plasticsurgery.org.au/information-for-patients/will-medicare-cover-my-procedure/)
- [Dr Kumar’s Surgical Fee Guide] – provided in consultation
About Dr Kumar
Dr Kumar is a specialist plastic surgeon with a strong focus on both reconstructive and cosmetic procedures. With years of experience helping patients achieve functional and aesthetic outcomes, Dr Kumar ensures every patient receives tailored care and transparency throughout the process.
Are you ready to book in with Dr Kumar?
