Does Medicare Cover Plastic Surgery?

Tue 4th Nov 2025

If you’re considering a surgical procedure, it’s essential to understand the potential costs and whether any rebates may apply. In Australia, Medicare provides benefits for certain procedures when specific criteria are met. This article outlines how Medicare coverage works and what factors determine eligibility.

Dr Eddy Dona is a Sydney-based Specialist Plastic and Reconstructive Surgeon. His practice includes a range of reconstructive and aesthetic (cosmetic) procedures. Some reconstructive procedures are listed under the Medicare Benefits Schedule, which outlines specific criteria for eligibility and rebates.

First up, let’s define the difference between cosmetic and reconstructive surgery.

• Cosmetic surgery is elective surgery. This means it’s not performed for medical reasons. It’s undertaken to change or reshape a normal part of the body for personal or aesthetic reasons.
• Reconstructive surgery is a type of plastic surgery performed to restore form and function to a body part affected by a congenital condition, illness, injury, or other medical or physical changes resulting from life events or lifestyle factors.

For a surgical procedure to be considered for Medicare benefits, it must meet the criteria for a reconstructive procedure as defined in the Medicare Benefits Schedule (MBS). If the criteria are met, an MBS item number may apply, which leads us to the next question.

What is a Medicare Item Number?

A Medicare item number is a unique code used to identify specific medical services or procedures listed on the Medicare Benefits Schedule (MBS). These codes are used to process claims for eligible Medicare rebates. For example, different item numbers apply to various services such as blood tests or GP appointments of differing lengths. In the case of reconstructive surgery, specific procedures may have associated MBS item numbers, depending on the nature of the surgery and the criteria outlined in the schedule.

“The only way to find out if you’re eligible for a Medicare rebate for your procedure is to have an Initial Consultation with Dr Dona.”

How Do I Know I’m Eligible For A Medicare Rebate?

The only way to determine whether you may be eligible for a Medicare rebate for a particular procedure is through an Initial Consultation with Dr Dona. During this appointment, your concerns will be discussed, and he will perform a clinical assessment. Based on this assessment, Dr Dona can advise whether the procedure is considered cosmetic or reconstructive and identify any relevant Medicare item numbers that may apply.

For example, if you’d like a Breast Augmentation (breast implants) for purely cosmetic reasons, your surgery will not attract a Medicare rebate.

At other times, some people may experience significant abdominal muscle separation following pregnancy. In some instances, if non-surgical management has been attempted without improvement, a reconstructive procedure may be considered. Eligibility for any Medicare benefit depends on the specific clinical circumstances and the criteria set out in the Medicare Benefits Schedule (MBS).

Getting a GP Referral For Plastic Surgery.

Before attending your Initial Consultation with Dr Dona, you will need a referral from your general practitioner (GP). A valid referral is required for both reconstructive and cosmetic procedures. This referral provides crucial medical information for the surgeon and helps ensure that your consultation and treatment are appropriately documented and clinically assessed.

Does Private Health Insurance Cover My Surgery?

Another vital consideration is Private Health Insurance. If a procedure is associated with a Medicare item number, Private Health Insurance may contribute to some of the hospital costs related to the surgery. The level of cover and eligibility for benefits will depend on the details of your individual policy, and higher-level hospital cover is often required to access them. We encourage patients to contact their health fund directly to confirm their level of cover and eligibility.

What Procedures Are Covered By Medicare?

There are many procedures listed under the Medicare Benefits Schedule (MBS), far too many to list here. Below are some of the more common reconstructive procedures performed by Dr Eddy Dona, provided as general examples.

It’s important to note that cosmetic procedures performed solely for aesthetic reasons are not eligible for Medicare rebates or Private Health Insurance benefits. Medicare determines the criteria for which procedures are eligible, and Dr Eddy Dona must assess each individual to determine whether their circumstances meet these criteria. In some cases, where a procedure addresses a functional issue such as muscle separation, skin irritation or discomfort caused by excess tissue, it may meet the requirements set out in the MBS for a rebate.

45523 – Bilateral Breast Reduction with Nipple Repositioning: Relates to Breast Reduction surgery for patients who experience physical symptoms such as neck, shoulder or back pain associated with large breast size (macromastia). It does not apply to procedures performed for cosmetic reshaping or breast enlargement.

 

30177 – Excision of Redundant Skin or Subcutaneous Tissue (Abdomen): Refers to the surgical removal of excess skin or tissue from the abdominal area following significant weight loss, where clinical symptoms such as skin irritation or recurrent infections are present. It does not apply to procedures undertaken for cosmetic purposes.

 

30175 – Radical Excision of Excess Skin and Fat (Abdomen, with Repair of Muscles): Relates to reconstructive surgery of the abdominal area that involves removing excess skin and tissue and repairing abdominal muscle separation (rectus diastasis). It may apply in cases such as following significant weight loss or pregnancy, where functional concerns are present. It does not apply to procedures performed for cosmetic purposes.

 

30169 – Excision of Excess Abdominal Skin and Fat, Post Weight Loss: Relates to the removal of redundant skin and tissue from the abdominal area following significant weight loss (greater than 5 BMI units). It may apply when documented medical issues, such as skin irritation or infections, are present.

 

30179 – Excision of Excess Skin, Trunk (Extended Procedures): Refers to extensive skin removal procedures, such as a Body Lift or circumferential excision, following major weight loss. It applies only where there is a medical indication rather than for cosmetic purposes.

 

30166 – Excision of Redundant Skin (Arm or Thigh Lift): Covers the removal of excess skin folds from the arms or thighs in cases where issues such as irritation, ulceration or infection have developed following significant weight loss.

 

31526 – Breast Reconstruction Using Tissue Expander or Implant: Applies to reconstructive breast surgery performed after mastectomy or trauma. It does not apply to cosmetic Breast Augmentation. Eligibility for Medicare item numbers is not automatic and must be assessed on an individual basis. Supporting information, which can include medical reports, photographs and referrals, is generally required to determine whether the clinical criteria set out in the Medicare Benefits Schedule (MBS) are met.

Understanding The Costs Of Plastic Surgery

Before proceeding with any plastic surgery procedure, it’s essential to understand all potential costs. After your Initial Consultation with Dr Eddy Dona, we’ll give you a detailed cost estimate.

In general, costs may include:

• Surgeon’s fee – The fee charged by the surgeon for performing the procedure. Fees vary depending on the complexity of the surgery and the surgeon’s training and experience.
• Theatre fee – The cost associated with the use of the operating facilities.
• Anaesthetist’s fee – Covers the administration of anaesthesia during surgery and may include prescribed pain relief for recovery.
• Medical supplies – Includes necessary items such as dressings, antibiotics, medical devices, compression garments and bandages.
• Hospital fee – Applies if an overnight hospital stay is required and relates to accommodation and hospital services.

Additional costs may also apply, such as those related to imaging, pathology, implants, post-operative care (for example, physiotherapy or wound care), hospital administration or other recovery-related services.

Medicare Rebate FAQs

What procedures are not covered by Medicare?

Many health services are not covered by Medicare, such as dental treatment, podiatry, physiotherapy, and ambulance transport. In plastic surgery, procedures performed solely for cosmetic purposes are not eligible for Medicare rebates. Examples include Breast Augmentation, Liposuction, Facelift and Buttock Augmentation.

What is no-gap surgery?

As the name suggests, no-gap surgery refers to an arrangement in which the patient is not required to pay any out-of-pocket costs for certain medical services. These arrangements are usually offered through specific Private Health Insurance programs or participating hospitals and can cover expenses such as hospital fees, surgeon’s fees and related medical services. It’s important to note that no gap arrangements generally do not apply to cosmetic or reconstructive plastic surgery procedures.

How can I claim a Medicare rebate?

If your procedure meets the Medicare criteria and you are eligible for a rebate, payment for your surgery is made in full at the time of treatment. Afterwards, our administrative team will provide a detailed receipt that includes any relevant Medicare item numbers. You can then submit your claim directly to Medicare, either online or in person. Once processed, any applicable rebate is deposited into your nominated bank account by Medicare.

Why choose a Specialist Plastic and Reconstructive Surgeon?

When considering surgery, it is essential to understand your surgeon’s qualifications and training. A Specialist Plastic and Reconstructive Surgeon, such as Dr Eddy Dona, has completed extensive accredited surgical training in both reconstructive and aesthetic procedures. This training covers complex surgical techniques aimed at restoring form and function, as well as procedures involving appearance-related concerns. Choosing a surgeon registered as a specialist with the Australian Health Practitioner Regulation Agency (AHPRA) helps ensure that they meet the recognised professional standards for this field.

To become a Specialist Plastic and Reconstructive Surgeon, the surgeon must complete accredited surgical training and meet the standards set by recognised professional organisations such as the Australian Society of Plastic Surgeons (ASPS).

Surgeons often develop a particular area of clinical focus. In Dr Dona’s case, this includes breast and Body Contouring procedures. This level of accredited training and experience ensures that the surgeon is qualified to perform complex procedures and manage associated surgical risks appropriately.

DISCLAIMER: The information provided here has been sourced from the official Medicare Benefits Schedule (MBS) and is intended for general educational purposes only. It does not constitute medical, financial or legal advice. Eligibility and rebate amounts depend on individual circumstances and assessment, and may change as the Medicare schedule is updated.