Does Medicare Cover Plastic Surgery? Everything You Need to Know

Cosmetic and reconstructive surgery almost always comes with a practical worry attached: what, if anything, will Medicare pay towards it? It comes down to one distinction: whether a procedure is medically necessary (reconstructive) or done purely to change appearance (cosmetic).

Purely cosmetic surgery attracts no rebate. A procedure that restores function or treats an underlying medical problem can, but only when it meets the specific criteria attached to its Medicare item number. Below are the procedures that commonly qualify, the thresholds each one has to clear, and how to lodge your claim once a surgeon confirms you’re eligible.

Key Insights

• Medicare rebates apply to reconstructive (medically necessary) surgery, not to procedures performed solely for appearance.
• Every eligible procedure has a Medicare Benefits Schedule (MBS) item number with strict criteria.
• You’ll need a GP referral to a specialist before your eligibility can be assessed.
• For in-hospital services, Medicare pays a benefit set at 75% of the MBS schedule fee; private health insurance may help with the remaining gap and hospital costs.
• If you don’t meet the criteria, the procedure is billed privately.

Is Plastic Surgery Covered by Medicare, or Only Sometimes?

Whether plastic surgery is covered by Medicare depends entirely on which side your procedure falls: cosmetic or reconstructive.

Cosmetic surgery changes appearance without treating a medical condition. A breast augmentation or a facelift done to look different is cosmetic, so it sits outside the rebate system entirely. That’s the case no matter how skilled the surgeon or how much the result matters to you personally.

Reconstructive surgery restores normal function or appearance after cancer treatment, injury, a congenital condition, or major weight loss. This is where Medicare can contribute, provided the procedure is listed on the MBS, and you meet the criteria written into the relevant item number.

Medicare looks at the primary purpose of the surgery, not the technique. The same operation can be cosmetic for one person and reconstructive for another. A breast reduction done to relieve chronic pain is assessed very differently from one done purely to change size, even though the surgery itself is the same.

When Does Medicare Cover Plastic Surgery? The Item Numbers and Their Criteria

Each procedure that Medicare recognises has an MBS item number, and each number carries its own list of conditions that must all be met. Your surgeon confirms which item applies and documents the evidence for it. For an in-hospital procedure, the Medicare benefit is 75% of the schedule fee for that item.

Here are the procedures we’re asked about most, with the criteria as they currently stand.

Breast Reduction (Items 45520 and 45523)

Breast reduction can attract a rebate when large breasts are causing a real physical problem, such as ongoing neck, shoulder or back pain, nerve symptoms, or skin breakdown in the fold. The bilateral item (45523) covers reduction for these functional symptoms. The unilateral item, 45520, is narrower: it applies to a one-sided reduction with repositioning of the nipple in the context of breast cancer or a developmental abnormality of the breast. A reduction done only to change appearance isn’t covered.

Breast Reconstruction After Mastectomy (Item 45527 and related items)

Reconstruction after breast cancer surgery is one of the clearest cases for Medicare support. Implant-based reconstruction, flap (own-tissue) reconstruction, nipple reconstruction and surgery to match the other breast can each qualify. Item 45527, for example, covers unilateral reconstruction following mastectomy using a permanent implant. Related item numbers cover the other reconstruction techniques.

Breast Implants for Medical Reasons (Items 45524 and 45528)

Breast augmentation with an implant can be covered when it’s reconstructive rather than elective. Item 45528 covers augmentation in the context of breast cancer, disease of or trauma to the breast (excluding trauma from previous elective cosmetic surgery), or amastia caused by a congenital endocrine disorder, with photographic or imaging evidence of the clinical need recorded in your notes. Item 45524 is the equivalent of a single breast with a documented volume difference of at least 20% (or 10% for tubular breasts). Augmentation for size or shape alone isn’t covered.

Breast Lift/Mastopexy (Item 45558)

A breast lift is usually cosmetic, but item 45558 can apply where the drooping is significant and documented. The threshold is specific: at least two-thirds of the breast tissue, including the nipple, must sit below the crease under the breast, with the nipple at the lowest point of the breast. If you’ve been pregnant, the lift must be done no sooner than 1 year and no later than 7 years after your most recent pregnancy. Photographic evidence with a marker at the fold is required, and the item is claimable only once in your lifetime.

Tummy Tuck After Major Weight Loss (Item 30177)

Item 30177 covers a tummy tuck (lipectomy with radical abdominoplasty) when redundant skin and fat are a direct result of significant weight loss. All of the following must apply:

• Significant weight loss, defined as a reduction equivalent to at least 5 BMI units.
• A skin condition, such as intertrigo (a rash or inflammation in the skin fold) that risks the skin breaking down, and that has failed at least 3 months of non-surgical treatment.
• Functional impact (the excess skin and fat interferes with everyday activities).
• Stable weight (your weight has been steady for at least 6 months after the weight loss, before surgery).

If your weight loss followed pregnancy, the weight of the baby, placenta and fluid isn’t counted in the starting figure.

Tummy Tuck for Muscle Separation After Pregnancy (Item 30175)

Introduced in July 2022, item 30175 covers a radical abdominoplasty with repair of rectus diastasis (separated stomach muscles) caused by pregnancy. Again, the criteria are numeric and must all be met:

• A diastasis of at least 3 cm, measured by diagnostic imaging such as an ultrasound before surgery.
• Documented symptoms (at least moderately severe pain or discomfort at the separation during everyday use, and/or lower back pain or urinary symptoms linked to the diastasis).
• Failed conservative treatment, including physiotherapy.
• At least 12 months since your most recent pregnancy.

It’s claimable once per lifetime, and only a standard abdominoplasty with muscle repair qualifies. A mini tummy tuck doesn’t. If you’re weighing up the private route as well, our page on what a tummy tuck costs sets out the picture when no item number applies.

Upper Eyelid Reduction (Item 45617)

Excess upper eyelid skin can hang far enough to block part of your vision. Item 45617 covers reduction of the upper eyelid when there’s a documented history of visual impairment caused by that excess skin (or inflammation within the eyelid fold). The item was amended on 1 November 2022 to remove the earlier visual field testing requirement, so a recorded history of demonstrated visual impairment is now the basis. Lower and upper eyelid surgery performed for appearance isn’t covered.

Arm and Thigh Lifts After Weight Loss

Arm lifts (brachioplasty) and thigh lifts follow the same functional test as the abdomen. Under the relevant weight-loss lipectomy items, the loose skin has to be a consequence of significant weight loss (again, at least 5 BMI units), your weight has been stable for at least 6 months, and the excess skin is causing functional problems. If two of these procedures are performed together in the same operation, Medicare and health fund rebates may be lost, even when each would qualify on its own. Done as separate operations, each can still attract a rebate.

Do You Need a GP Referral?

Yes. A GP referral to a specialist or reconstructive surgeon does three things: it makes your specialist consultation eligible for a Medicare rebate, it gets your situation in front of someone who can assess which item number might apply, and it starts the paper trail Medicare will want to see.

Your GP recording your symptoms along with photographs, where relevant, is what builds the case for coverage. It’s worth booking that appointment early and being specific about the physical problems you’re experiencing, because those details are exactly what the criteria turn on.

A valid referral is usually needed for a private health insurance claim, too.

How to Claim Your Medicare Rebate Once You’re Approved

Being eligible and receiving the rebate are two different steps. Here’s how the claim comes together:

• Get your GP referral to a specialist surgeon experienced in both cosmetic and reconstructive work.
• Have your eligibility confirmed. At your consultation, the surgeon identifies the correct MBS item number and records the required evidence – measurements, imaging, photographs, symptom history and any failed non-surgical treatment. This evidence is what supports the item number if the claim is ever reviewed.
• Proceed with surgery under that item number. For an in-hospital procedure, Medicare pays 75% of the schedule fee for the item, and your health fund may contribute towards the hospital costs and part of the gap, depending on your level of cover.
• Lodge the claim. In most cases, the surgeon’s rooms or the hospital submits the Medicare claim electronically on your behalf. If you need to claim yourself, you can do it through your Medicare online account via myGov, the Express Plus Medicare app, or by lodging a claim form with Services Australia.
• Keep your paperwork. These item numbers can be audited, so hold on to the referral, reports and imaging.

Meeting the criteria doesn’t automatically authorise billing any amount. The item number sets the schedule fee, and the rebate is calculated from that, not from the surgeon’s actual fee.

What If You Don’t Qualify?

So, is plastic surgery covered by Medicare? Only when it does real medical work, and only when your case meets the criteria for a specific item number.

Plenty of people don’t meet the thresholds, which means the procedure is billed privately. If that’s you, the more useful question becomes what the surgery will cost. Our guide to what surgery actually costs and our surgical pricing page lay that out, and some patients also look into early release of superannuation as an option.

If you’d like this properly assessed for your situation, our team is happy to help. Call Breast & Body Clinic on (02) 9819 7449 or book a confidential consultation, and we’ll talk you through whether your procedure is likely to meet an MBS item number and what documentation you’ll need.