Medicare for Blepharoplasty

Does Medicare Cover Blepharoplasty Surgery in Sydney?

Medicare Australia is a government-funded healthcare system that provides access to medical services for Australian residents. It plays a crucial role in ensuring that individuals have access to essential medical treatments and procedures, including surgeries.

In this blog, Sydney Specialist Plastic Surgeon Dr Jake Lim will explore the coverage provided by Medicare Australia for Blepharoplasty surgery, also known as eyelid surgery.

What Is Blepharoplasty Surgery?

Blepharoplasty surgery is a cosmetic procedure that aims to improve the appearance of the eyelids. It involves the removal of excess skin, fat, and muscle from the upper or lower eyelids, resulting in a less hooded look. This surgery can be performed for both aesthetic reasons and to address functional issues such as impaired vision caused by drooping (ptotic) eyelids.

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Medicare Rebate for Blepharoplasty Surgery

Medicare Australia provides a rebate for certain medically necessary surgical procedures, including Blepharoplasty surgery. However, it’s important to note that Medicare rebate for cosmetic procedures is limited. To be eligible for a Medicare rebate, the surgery must be deemed medically necessary by a qualified healthcare professional.

Blepharoplasty Item Numbers

Medicare Australia uses a system of item numbers to categorise and rebate medical procedures. Each medical service, including Blepharoplasty surgery, is assigned a specific item number.

The Medicare Australia Medical Benefits Schedule (MBS) item numbers for Blepharoplasty are 45617 for upper eyelid reduction and 45620 for lower eyelid reduction.

MBS item number 45617 covers reduction of the upper eyelid if there is a history of demonstrated visual impairment or if there is intertriginous inflammation of the eyelid. Additionally, it also covers conditions involving ptotic (drooping) eyelid skin, where the drooping significantly impacts the field of vision
MBS item number 45620 covers a reduction of the lower eyelid under specific clinical circumstances. The reduction procedure is covered if it’s performed for herniation of orbital fat in cases of exophthalmos, facial nerve palsy, or post-traumatic scarring; or restoration of symmetry of the contralateral lower eyelid concerning one of the conditions mentioned above. It’s essential to have photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service, and such evidence must be documented in the patient notes.

It’s implied that the procedure is aimed at addressing medical conditions rather than for cosmetic purposes. The clinical need for the service must be demonstrated, and it could be subject to audit to ensure compliance with the MBS requirements.

Eligibility Criteria for Medicare Rebate

To be eligible for a Medicare Rebate for Blepharoplasty surgery, certain criteria must be met. The surgery must be performed by a registered medical practitioner who is recognised by Medicare Australia. The surgery must be deemed medically necessary due to functional impairment or significant psychological distress caused by the appearance of the eyelids. A referral from a general practitioner or specialist is required to establish the medical necessity.

To qualify for a Medicare Australia rebate for Blepharoplasty, there are specific eligibility criteria that need to be satisfied. Here is a summary:

Clinical Need Documentation: Patients must demonstrate and document the clinical need for the surgery to be eligible for a Medicare rebate. It’s required to have photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service, and such evidence must be documented in the patient notes
Medical Assessment: Patients may be required to seek an opinion from a professional who will perform a test to check how the loose skin affects their vision. Dr Lim will advise you at consultation if this is required
Vision Impairment: Medicare may cover a portion of the surgeon’s fees and anaesthetic fees if the upper eyelids impair the vision. The procedure is more likely to be rebated if the ptotic (droopy) eyelid skin impacts the field of vision or if the eyelid skin sags or droops to the point where it affects vision
Specific Conditions: For lower eyelid reduction under MBS item number 45620, the reduction procedure is rebated if it’s performed for herniation of orbital fat in cases of exophthalmos, facial nerve palsy, or post-traumatic scarring, or for the restoration of symmetry of the contralateral lower eyelid concerning one of these conditions

These eligibility criteria are set to ensure that the procedure is medically necessary rather than for cosmetic purposes. Patients seeking Medicare coverage for Blepharoplasty should consult with a medical professional to understand if they meet the eligibility criteria and to get the necessary documentation and assessments done.

Steps to Claim Medicare for Blepharoplasty Surgery

If you meet the eligibility criteria for Medicare coverage, you can proceed with claiming Medicare benefits for your Blepharoplasty surgery. The first step is to consult with your GP who will provide you with a referral to see Dr Jake Lim.

Next, you will need to have a consultation and then schedule the surgery with Dr Jake Lim. Dr Lim will perform the surgery and his team will provide you with the necessary documentation, including an itemised invoice so you will be able to process your claim through Medicare.

Limitations and Restrictions of Medicare rebates

While Medicare Australia provides rebates for Blepharoplasty surgery under certain circumstances, it’s important to be aware of the limitations and restrictions. A Medicare rebate is limited to the surgical removal of excess skin, fat, and muscle from the eyelids. Any additional procedures or treatments, such as the removal of eye bags or the correction of wrinkles around the eyes, may not be rebated by Medicare.

Furthermore, Medicare rebates for Blepharoplasty surgery may only extend to the cost of the procedure itself. Additional expenses, such as hospital fees, anaesthetist fees, and any necessary post-operative care, may not be fully covered by Medicare. It’s important to discuss these potential costs with your plastic surgeon and private health insurer, if applicable, to understand the financial implications of the surgery.

Private Health Insurance and Blepharoplasty Surgery

Private health insurance can supplement a Medicare rebate for Blepharoplasty surgery. Depending on your insurance policy, you may be eligible for coverage for additional expenses associated with the surgery, such as hospital fees, anaesthetist fees, and post-operative care. However, it’s essential to review your policy and consult with your insurer to understand the extent of your coverage and any out-of-pocket expenses you may incur.

Alternative Financing Options for Blepharoplasty Surgery

If you do not have private health insurance or if your insurance policy does not cover the full cost of Blepharoplasty surgery, there are alternative financing options available such as payment plans or financing arrangements to help you manage the cost of the procedure. Additionally, there are medical finance companies that specialise in providing loans specifically for medical treatments and procedures.

Understanding Medicare Australia rebates for Blepharoplasty surgery is essential if you are considering this procedure. While Medicare does provide a rebate for medically necessary Blepharoplasty surgery, it’s important to meet the eligibility criteria and be aware of the limitations and restrictions. Private health insurance can help supplement Medicare rebates, and alternative financing options are available for those who require additional financial assistance.

FAQs about Medicare for Eyelid Surgery

Can I get a Medicare rebate for cosmetic blepharoplasty?

Medicare Australia does not cover the costs for cosmetic blepharoplasty. Rebates are only provided for medically necessary blepharoplasty procedures where the droopy eyelids significantly impair vision and there is a clinical need for the surgery.

What specialists should I consult for eligibility assessment?

Dr Lim will advise you if you are required to carry out a visual field test to evaluate how your loose or droopy eyelid skin affects your vision. If required, you should then consult an ophthalmologist or optometrist for an assessment. Then consult with Dr Lim’s team, they will advise you on your eligibility for a Medicare rebate.

What is the process to apply for a Medicare rebate for blepharoplasty?

After consulting with a plastic surgeon, if it’s determined that the procedure is medically necessary, your plastic surgeon will help you with the documentation required to apply for a Medicare rebate. You may also need to provide photographic and/or diagnostic imaging evidence as part of the application process.

Is there a specific MBS item number I should be aware of for blepharoplasty coverage?

Yes, there are specific MBS item numbers for blepharoplasty: item number 45617 for upper eyelid reduction and item number 45620 for lower eyelid reduction. These item numbers are tied to the eligibility criteria and documentation requirements for Medicare rebate.

Can I choose any surgeon for blepharoplasty under Medicare?

It’s recommended to choose a specialist plastic surgeon registered with Medicare. This ensures that the surgeon meets the professional standards required for the procedure and increases the likelihood of obtaining a Medicare rebate for medically necessary blepharoplasty.

Medical References about Blepharoplasty

Blepharoplasty | Cosmetic Surgery – Stanford Medicine
Blepharoplasty – Mayo Clinic
Blepharoplasty: An Overview – PMC
Eye Lift: Blepharoplasty (Eyelid Surgery) Information -WebMD