A Closer Look at Medicare Rebates for Aesthetic Surgery

Aesthetic surgery is gaining popularity in Australia – offering solutions that range from purely cosmetic to medically necessary procedures. It is no surprise then, that there is an increasing number of people seeking information on Medicare rebates for aesthetic surgery.

Despite the fact that there is an increasing interest on this topic, navigating Medicare coverage for aesthetic and functional aesthetic surgery in Australia can be quite confusing and overwhelming for most, and we frequently receive questions about which procedures qualify for the coverage benefits.

Medicare’s coverage policy is based on a straightforward principle – procedures performed purely for aesthetic reasons aren’t covered, while those performed to restore function, or alleviate medical issues, may qualify for rebates. Having said this, the line between these procedures isn’t always clear, and applying these principles to individual cases requires meeting specific criteria and documentation requirements.

In this blog, we will look at the different ways in which Medicare assesses aesthetic and functional aesthetic surgery, which surgeries commonly qualify for rebates, and the steps you need to take to determine your eligibility. We will also take a closer look at procedures such as a scar revision, breast lift (mastopexy), and whether Medicare can be an option for these. Knowing your options can help you plan ahead – financially and medically.

The information provided is current as of April 2025, but we recommend visiting the official Medicare website for the most up-to-date details, as policies and rebate amounts may change.

Medicare and Cosmetic Procedures: Reconstructive vs Cosmetic Surgery

When it comes to Medicare coverage for aesthetic surgery, a key factor is whether the procedure is classified as cosmetic or reconstructive.

Cosmetic surgery is performed to enhance appearance without addressing a medical concern. While cosmetic procedures can have a positive impact on self-esteem, they are not considered medically necessary — and therefore are not covered by Medicare. For instance, a facelift or a breast augmentation done that are done solely for aesthetic purposes will not be eligible for rebates.

Reconstructive surgery is performed to restore normal appearance or function after injury, illness, congenital abnormalities, or significant weight loss. When it comes to reconstructive surgery, Medicare Australia provides coverage for a range of procedures deemed medically necessary, including those following trauma, cancer treatment, or congenital abnormalities.

Having said this, there are specific item numbers in the Medicare Benefits Schedule (MBS) that determine coverage eligibility. Each item number contains detailed criteria that must be met for the procedure to qualify for a rebate.

For example:

• Breast reconstruction following mastectomy — including implant-based reconstruction, flap (autologous tissue) reconstruction, nipple reconstruction, and symmetry procedures on the unaffected breast — may be eligible under Medicare Items 45530–45558 when medically indicated after breast cancer treatment.
• Abdominoplasty (tummy tuck) after significant weight loss may be covered under Medicare Item 30177 when the patient experiences chronic skin infections, rashes, or functional impairment caused by excess skin, supported by photographic and clinical documentation.
• Abdominoplasty post-pregnancy may qualify for a Medicare rebate under Item 30175, provided the patient meets strict criteria including significant rectus diastasis (muscle separation) of at least 3cm, and associated pain or functional limitations that impact daily living.
• A breast lift (mastopexy) for someone experiencing chronic skin irritation under the breast fold due to significant breast ptosis may be eligible under Medicare Item 45558.
• A breast reduction for a patient suffering from chronic back, neck, or shoulder pain, or restricted physical activity due to large breasts may qualify under Item 45523.
• Scar revision or corrective surgery after an accident or cancer treatment also falls under reconstructive surgery.

Another important point is that Medicare’s determination is based on the primary purpose of the surgery, not the technique used. A procedure that might be considered cosmetic in one patient could be deemed reconstructive in another, depending on the underlying medical need.

Do You Need a GP Referral for Functional Aesthetic Surgery?

Yes — if you’re considering Medicare rebate for a surgery, obtaining a GP referral is an important first step.

A Medicare rebate GP referral ensures:

• You’re seeing a specialist or reconstructive surgeon.
• Your consultation is eligible for a Medicare rebate.
• The surgeon can assess your situation for MBS item number eligibility.

This is needed even when you’re seeking a procedure for functional or reconstructive reasons (like breast reduction due to back pain or a lift after massive weight loss). A detailed documentation from your GP (including photographs) about your symptoms or health concerns helps build your case for Medicare coverage.

Additionally, a valid referral is usually required for private health insurance claims as well. It’s best to speak to your GP early and explain the physical or medical symptoms you are experiencing that relate to the surgery you’re seeking.

The Medicare Benefits Schedule (MBS) Explained

The Medicare Benefits Schedule is a detailed listing of all medical services subsidized by the Australian government. Understanding how it works is essential to navigating Medicare rebates for aesthetic surgery.

How Medicare Rebates Work

Medicare rebates are calculated as a percentage of the schedule fee set by the government:

• For in-hospital services, Medicare covers 75% of the schedule fee
• For out-of-hospital services, Medicare covers 85% of the schedule fee

However, it’s crucial to understand that surgeons could charge more than the schedule fee – creating a gap between the coverage and actual fees. This gap payment represents your out-of-pocket expenses.

Using the Medicare Rebate Calculator

While there is no official Medicare rebate calculator provided by the government, you can calculate your potential rebate by:

1. Identifying the relevant MBS item number for your procedure
2. Looking up the schedule fee on the MBS Online website
3. Calculating 75% of that amount for in-hospital procedures

For example, if a breast reconstruction procedure has an MBS item number with a schedule fee of $1,000, the Medicare rebate would be $750 for an in-hospital procedure.

Understanding Item Numbers

Each procedure in the MBS has a unique item number with specific criteria. For example:

• Item 45520: Breast reconstruction following mastectomy
• Item 45617: Breast reduction for significant physical symptoms

Medicare coverage for aesthetic and functional surgery depends entirely on meeting all criteria listed under the relevant item number. Your surgeon must confirm that your condition satisfies these requirements before Medicare benefits can be claimed.

Gap Payments and Out-of-Pocket Costs

The difference between what Medicare pays and what your surgeon charges could be substantial. For example:

• Schedule fee for a procedure: $1,000
• Medicare rebate (75%): $750
• Surgeon’s actual fee: $3,000
• Your gap payment: $2,250

Over and above the surgeon’s fees, you might also incur some additional charges such as the anaesthetist fee, hospital or clinic fees and other out-of-pocket expenses. Private health insurance may cover some of this gap, but policies vary significantly. It is always a good idea to check with both your surgeon and your insurance provider about expected out-of-pocket expenses before proceeding with any procedure.

For the most current information on rebates and eligibility criteria, the official MBS Online website provides detailed, up-to-date listings of all Medicare item numbers and their associated criteria.

Understanding Medicare coverage for surgery — particularly for procedures that blur the line between cosmetic and reconstructive — can be complex. But with the right guidance and information, you can make informed decisions about your body, health, and finances.

If you’re considering a breast lift, abdominoplasty, or any other aesthetic surgery, your next step should be:

• Book an appointment with your GP to discuss your symptoms and explore eligibility for Medicare rebates.
• Consult with a specialist specialist surgeon who is experienced in both cosmetic and reconstructive procedures — and familiar with the Medicare system.

At Breast & Body Clinic, we prioritise your wellbeing and are here to guide you through the process — from understanding your Medicare benefits for surgery to delivering personalised care and natural-looking results.

Ready to find out if you’re eligible for a Medicare rebate?

Reach out today to book your confidential consultation and take the first step toward feeling confident, healthy, and informed.

Frequently Asked Questions About Medicare and Cosmetic Surgery

Here are answers to a few frequently asked questions around Medicare coverage for aesthetic and cosmetic surgery in Australia: