Will Medicare Cover My Labiaplasty in Sydney?

Medicare Cover for Labiaplasty Surgery

Labiaplasty is a procedure for women, not just for its cosmetic appeal but also for the medical relief it offers to many. This surgical procedure, which involves altering the labia for various reasons, has seen an increase in interest. However, with this increased attention comes an important question: “Will Medicare cover my labiaplasty?”

In this blog, Sydney Plastic Surgeon Dr Jake Lim will discuss the details of Medicare coverage for labiaplasty in Sydney. He will explore what labiaplasty entails, differentiate between cosmetic and medically necessary procedures, and get into the specifics of Medicare’s policies.

Key Features of Labiaplasty Surgery

Labiaplasty is a surgical procedure that involves the resizing or reshaping of the labia minora and/or labia majora, the external parts of the female genitalia
It aims to alleviate discomfort, improve functionality, or enhance the aesthetic appearance of the genital area

Benefits of Labiaplasty include physical comfort and hygienic improvement. After the surgery, patients may notice a reduction in irritation and discomfort in tight clothing or during physical activities like cycling or running. In some cases, it can help with better hygiene in the genital area
Procedure details: Typically it involves either trimming excess tissue or reconstructing the labia to a preferred size and shape. It is usually performed under a general anaesthesia.
The procedure usually takes 1 to 2 hours
Immediate Post-Op: Patients may experience bruising, swelling and discomfort initially, which can be managed with prescribed pain medication and cold compresses.
Most patients can return to work within 2 weeks, but should avoid strenuous activities for up to 4-6 weeks
Complete healing can take up to 6 months, during which time patients should follow specific care instructions provided by Dr Lim
As with any surgery, labiaplasty carries risks such as infection, bleeding, and scarring. Sensitivity changes in the treated area are possible

Is Labiaplasty Covered by Medicare in Sydney?

When considering labiaplasty in Sydney, one of the primary concerns is whether this procedure is covered by Medicare. Understanding the conditions of Medicare coverage is essential for anyone contemplating this surgery.

Medicare covers medically necessary procedures. However, when it comes to labiaplasty, the line between ‘cosmetic’ and ‘medically necessary’ can often be blurred. It’s important to understand that Medicare’s coverage for labiaplasty is not black and white; it varies based on individual circumstances and medical justifications.

Criteria for Medicare Coverage

To qualify for Medicare coverage, labiaplasty must be deemed medically necessary. This means the procedure is required to resolve health issues, such as chronic irritation, pain, or recurrent infections, rather than for purely aesthetic reasons. The following are factors that might influence Medicare’s decision:

Chronic Physical Discomfort: If the labia cause significant and ongoing physical discomfort that interferes with daily activities, such as walking, exercising, or sexual intercourse
Recurrent Infections or Hygiene Issues: Cases where the size or shape of the labia contribute to repeated infections or pose significant hygiene challenges

Documentation and Medical Assessments

To apply for Medicare coverage, proper documentation from a qualified healthcare provider might be necessary. This can include:

Medical History and Physical Examination: Detailed records demonstrating the physical and/or psychological impact of the labial size or shape
Letters or Reports from Specialists: Input from gynaecologists or other relevant specialists can support the case for medical necessity
Photographic Evidence: In some cases, visual documentation may be required to illustrate the extent of the issue

Medicare Benefits Schedule Item Numbers for Labiaplasty

In Australia, the Medicare Benefits Schedule (MBS) provides specific item numbers for various medical procedures, including labiaplasty. These item numbers are important for patients and healthcare providers as they determine whether a procedure can be subsidised by Medicare. For labiaplasty, two primary MBS codes are often referenced: 35533 and 35534. These codes can provide insight into what conditions are covered by Medicare and the nature of the procedures.

MBS Code 35533

The Medicare Benefits Schedule (MBS) Code 35533 is a specific item number that covers vulvoplasty or labioplasty procedures under certain conditions. This code falls under Category 3 – Therapeutic Procedures, within Group T8 (Surgical Operations) and Subgroup 4 (Gynaecological). The key aspects of MBS Code 35533 are as follows:

Procedure Description: MBS Code 35533 is designated for vulvoplasty or labioplasty procedures that are performed for the repair of either female genital mutilation or anomalies associated with major congenital anomalies of the uro-gynaecological tract
Eligibility Criteria: This item is specifically intended for procedures that are not associated with services covered by other specific MBS items, such as 35536, 37836, 37050, 37842, 37851, or 43882
Purpose of the Procedure: The primary focus of MBS Code 35533 is to provide coverage for surgical repairs related to severe conditions like female genital mutilation or significant congenital anomalies. These conditions often require specialised surgical intervention for repair and reconstruction
Financial Aspects: The fee for a procedure under this item is $385.05, with a Medicare benefit of 75%, which amounts to $288.80. This indicates the rebate amount that Medicare contributes towards the cost of the procedure

Associated Notes for MBS Code 35533

Intended Coverage: MBS Code 35533 is designed to cover the surgical repair of female genital mutilation or major congenital anomalies of the uro-gynaecological tract that are not addressed by other MBS items. This includes conditions like cloacal extrophy, bladder exstrophy, or congenital adrenal hyperplasia that may require additional or follow-up treatment
Documentation Requirements: For a procedure to be covered under this item, a detailed clinical history outlining the need for surgery of the vulva and/or labia must be included in patient notes. This documentation is crucial as it may be subject to audit by Medicare
Exclusion of Cosmetic Services: It’s important to note that Medicare benefits are not payable for non-therapeutic cosmetic services under this item. The focus is strictly on therapeutic, medically necessary procedures

MBS Code 35534

The Medicare Benefits Schedule (MBS) Code 35534 pertains to a specific type of surgical procedure, namely vulvoplasty or labioplasty. This item is categorised under Category 3 – Therapeutic Procedures, falling within Group T8 (Surgical Operations) and Subgroup 4 (Gynaecological). The key details of MBS Code 35534 are as follows:

Procedure Description: This item covers vulvoplasty or labioplasty procedures. It is specifically intended for patients aged 18 years or older
Eligibility Criteria: The procedure must be performed by a specialist in their field of specialty. It is applicable for patients who have a structural abnormality that causes significant functional impairment. A critical condition for eligibility is that the patient’s labium must extend more than 8 cm below the vaginal introitus while standing in a resting position
Purpose of the Procedure: MBS Code 35534 is designed to address cases where there is a structural abnormality leading to significant functional impairment. This could include issues that affect the patient’s daily life, physical comfort, or other functional aspects related to the labia
Financial Aspects: The fee for a procedure under this item is $385.05, with a Medicare benefit of 75%, equating to $288.80. This indicates the amount that Medicare contributes towards the cost of the procedure

Associated Notes for MBS Code 35534

Intended Coverage: MBS Code 35534 is intended to cover services for structural abnormalities causing significant functional impairment. It is restricted to patients aged 18 years and over
Documentation Requirements: A detailed clinical history outlining the structural abnormality and the medical need for surgery of the vulva and/or labia must be included in patient notes. This is crucial as it may be subject to audit
Exclusion of Cosmetic Services: It is important to note that Medicare benefits are not payable for non-therapeutic cosmetic services. This means that the procedure must be medically necessary and not purely for cosmetic enhancement

MBS Code 35534 vs MBS Code 35533

While both items address gynecological surgical procedures, MBS Code 35533 is more focused on repairing damage from genital mutilation or congenital anomalies, whereas MBS Code 35534 is specific to structural abnormalities causing significant functional impairment.

What If Medicare Does Not Cover Labiaplasty?

In cases where Medicare does not cover labiaplasty, there are other avenues to explore:

Private Health Insurance: Some private health insurance plans may offer partial coverage for labiaplasty, especially if it’s considered medically necessary. It’s important to check with your insurance provider
Payment Plans and Financing: Some surgical clinics offer payment plans or financing options to make the procedure more affordable
Out-of-Pocket Expenses: If other options are not viable, paying out-of-pocket may be the only route. In this case, it’s important to get a clear understanding of all the costs involved, including post-operative care

FAQs about Medicare and Labiaplasty

Why would someone get a labiaplasty?

Individuals may choose to undergo labiaplasty for a variety of reasons. The procedure is sought by those experiencing physical discomfort or pain during activities like cycling, walking, or sexual intercourse due to the size or shape of their labia

What makes labiaplasty medically necessary?

Labiaplasty is considered medically necessary in cases where the size or shape of the labia causes chronic irritation, pain, or hygiene issues. Women suffering from labial hypertrophy (enlarged labia) may experience discomfort during physical activities, difficulties in maintaining genital hygiene, or pain during sexual activities. In such scenarios, labiaplasty is not just a cosmetic procedure but a medical intervention to alleviate physical and functional discomfort.

Is labiaplasty common in Australia?

In recent years, labiaplasty has become more common in Australia, mirroring a global increase in cosmetic genital surgeries. This rise can be attributed to greater societal acceptance, increased awareness of the procedure, and the influence of media and cultural trends. Australian women are increasingly seeking labiaplasty for both cosmetic and medical reasons, although exact numbers are hard to pinpoint due to the private nature of the procedure.

What is the alternative to labiaplasty?

For those seeking alternatives to labiaplasty, there are non-surgical options available. These include laser treatments, which can tighten and reshape the labia without invasive surgery. Hormonal treatments may also be considered, especially if the labial issue is related to hormonal imbalances.

How much is labiaplasty in Sydney?

The cost of labiaplasty in Sydney varies widely depending on several factors, including the surgeon’s experience, the complexity of the procedure, and the facility where it is performed. Generally, prices can range from a few thousand to several thousand Australian dollars. It’s important for patients to consult with multiple clinics and surgeons to get a clear understanding of the costs involved, and also to consider the potential need for follow-up care or additional procedures, which can add to the overall expense.

Medical References about Labiaplasty and Medicare

Labiaplasty: Surgery, Recovery & What To Expect – Cleveland Clinic
What is a labiaplasty and what does it involve? – American Society of Plastic Surgeons
Cosmetic genital surgery – labiaplasty and phalloplasty – Better Health Channel
Vaginal Plastic Surgery: Vaginoplasty and Labiaplasty – WebMD
Labiaplasty Minora Reduction – StatPearls