Will Medicare Cover My Eyelid Surgery?

Dr Scott Turner - FRACS (Plas)

How to get Medicare and Health Insurance to Help Pay for Eyelid Surgery

Can you get Medicare to Cover Eyelid Surgery?

Some patients get Medicare coverage for eyelid surgery through item numbers 45617 and 45620. However, to justify the claim, the surgical procedure must be seen as a medical necessity by the surgeon as well as Medicare. It essentially means that you are getting the surgery done for medical reasons instead of purely aesthetic ones. Medicare does not pay for elective procedures.

PLEASE NOTE – Dr Turner does not offer FREE Eyelid surgery. Medicare and/or your Private Health Insurer may offer a PARTIAL SUBSIDY for a procedure to be done in a private plastic surgery practice like Dr Turner’s. There will still be a SIGNIFICANT GAP PAYMENT for your surgery that you have to pay for.

FREE plastic surgery MAY be available in some public hospitals for some procedures but there is a significant waiting period – sometimes many years spent waiting for elective surgery. If you want your surgery sooner than that and can’t afford it – please consider other funding options.

Dr Scott Turner is an experienced Plastic Surgeon and Eyelid Surgery Expert – find out more about the eyelid procedures and have a look at his patients before and after photos.

What are the Criteria for Getting Medicare for Eyelid Surgery?

There are various eye health concerns that can help you qualify for Eyelid Surgery and make it a medical necessity:

  • The excess skin on your eyelids is diagnosed by physical examination
  • You experience at least 30% or 12 degrees of obstruction of the visual field caused by the excess skin on your eyelids
  • You have photographs and documentation of visual problems as proof that can be submitted to Medicare
  • Medicare-approved physicians must state the surgery is medically necessary
  • Trauma has caused defects to your eyelid
  • You are experiencing problems with eyelids due to nerve plasty or thyroid disease

Quick Facts about Medicare Cover for Eyelid Surgery

What is Eyelid Surgery?

Eyelid surgery, also known as Blepharoplasty, is a surgical procedure designed to remove excess skin and fat from the dropping eyelids. The surgery can be performed on upper, lower eyelids or both. With age, the skin stretches and the supporting muscles lose their efficiency, causing the eyelids to droop. Excessive skin sagging can hinder the vision and simple functioning of opening/closing eyes. For more information visit the eyelid surgery page

Why Should I Consider an Eyelid Surgery?

There are many medical and aesthetic reasons for getting eyelid surgery done. Some of them are listed below:

·       Improve Your Vision

Excess, droopy skin from the upper eyelid can obstruct your peripheral vision. By removing the unwanted skin, your vision can improve significantly.

·       Look More Refreshed

Heavy and droopy eyelids can make you look constantly tired. If you are tired of people asking you; are you sick or have you slept well, eyelid surgery might just be the right option for you.

·       Look More Youthful

Heavy and droopy eyelids can make you look years older than your age. This is particularly a problem when heavy eyelids are the only signs of aging on your face. Eyelid surgery can make you look more youthful and alert.

·       Easier Cosmetic & Makeup Application

Excess skin on the eyes can make the makeup application process extremely troublesome. Almost anything and everything looks bad on loose skin on the eyelids. If you are a makeup fan, it can open a lot of eye makeup options for you.

·       Bags under Your Eyes

If you are bothered by the appearance of bags underneath your eyes, eyelid surgery can help fix this problem for you.

·       Improved Confidence

With youthful, refreshed, alert-looking eyes and no vision obstructions, your confidence can improve and affect nearly every part of your life.

You’ll need a Medical Referral with Documented Concerns

In order to claim your surgery on Medicare, you will need a Medical Referral from your General Practitioner (GP). You can get it prior to booking an initial consultation with Dr Turner or after the first appointment.

It is important to demonstrate medical necessity, including photographic proof. While consulting with your GP, it is worth discussing your symptoms to ensure the clinical need is documented in your referral.

So will My Eyelid Surgery be Covered by Medicare?

The answer to this is ‘MAYBE’ – Medicare offers rebates on eyelid procedures if you meet the special criteria and conditions as listed below.

How Do You Qualify for Medicare Rebate for Eyelid Surgery? – MBS Codes

Medicare Item Number 45617

Upper eyelid, reduction of, if:

(a) the reduction is for any of the following:

(i) skin redundancy that causes a visual field defect (confirmed by an optometrist or ophthalmologist) or intertriginous inflammation of the eyelid;

(ii) herniation of orbital fat in exophthalmos;

(iii) facial nerve palsy;

(iv) post-traumatic scarring;

(v) the restoration of symmetry of contralateral upper eyelid in respect of one of the conditions mentioned in subparagraphs (i) to (iv); and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

Medicare Item Number 45620

Lower eyelid, reduction of, if:

(a) the reduction is for:

(i) herniation of orbital fat in exophthalmos, facial nerve palsy or post-traumatic scarring; or

(ii) the restoration of symmetry of the contralateral lower eyelid in respect of one of these conditions; and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

What are the Eyelid Surgery criteria in Australia?

People who meet the strict conditions associated with these item numbers can qualify for Medicare rebates in Australia: 45617, 45620.

Will Health Insurance Help Cover the Cost of Eyelid surgery?

If the eyelid surgery is deemed medically necessary and you are eligible for a rebate along with having the right level of health insurance then some of your costs might be covered. If you are not insured you may still be entitled to a Medicare rebate.

If you DO NOT meet the Medicare criteria, there will be NO rebate or reimbursement from either Medicare OR from your health fund.

You can ask your Surgeon to assist you in this regard during the consultation. It is always a good idea to check in with your private insurance directly to see if you have the right cover and they will cover the costs associated with the surgery or not.

Why is the Medicare Rebate for Eyelid Surgery Confusing?

This is due to the variables of the situation. Each patient is different and has different reasons for getting the eyelid surgery done.

In some cases, Medicare offers a minor rebate on certain procedures. It is important to note that rebates are generally available for reconstructive plastic surgery only if the surgery is deemed ‘essential’. For some patients, eyelid surgery will be under this category.

When it comes to Plastic & Cosmetic Surgery, the Medicare REBATE guidelines are quite clear. Medicare does not cover ‘non-therapeutic cosmetic surgery’ NOR ‘non-therapeutic plastic surgery’ procedures.

NOTE – Medicare Rebates are subject to change and review

Please note that MBS Item codes are reviewed regularly and can be changed/eliminated from the Medicare rebate schedule at any time. If you are currently eligible for a Medicare rebate for eyelid surgery, it is best to get the procedure sooner rather than later.

How Much Will Eyelid Surgery Cost if Self-Funded?

The costs vary for upper or lower eyelid surgery. When the procedure is performed on both the upper and lower eyelids the fees are higher. Visit the surgery pricing page for more information.

The cost of eyelid surgery varies based on your geographical location, experience and expertise of the surgeon, the hospital facility, and your unique case. It is primarily due to the fact that eyelid surgery is a highly customised procedure and people get it done due to different reasons. You can contact Dr Turner’s team for an estimate or come for a consultation to get a quote. We will also help you understand the costs and risks associated with the surgery. Our team can also help you access your eligibility for coverage by MBS or your health fund.

In order to access your eligibility to claim a Medicare rebate for your Eyelid Surgery, visit your GP or other specialist and ask for a referral to Dr Turner. You will need a valid referral at the time of surgery. A GP referral lasts for 12 months.

You can also speak to our knowledgeable Patient Care Team, who are available to answer your questions. 

Visit the surgical costs page for more information and download the guide.

Funding your Eyelid Surgery

Can I Use My Super Fund to Pay for Eyelid Surgery?

Some patients use their own super fund to pay for their eyelid surgery. Before requesting the early release of funds, it is very important to note that:

  • Each application for early Super release is assessed on an individual basis and financially assessed
  • Superfund withdrawal applications can be made through your MYGOV account via the ATO
  • Tax implications apply. The withdrawal may be taxable. Hence, it is important to seek professional financial advice

FAQ on Medicare for Eyelid Surgery

Here is a list of frequently asked questions we get regarding Medicare and Eyelid Surgery:

What MBS Codes are associated with Eyelid Surgery?

  • Patients can get Medicare coverage for eyelid surgery through item numbers 45617 and 45620.

Can eyelid surgery be a medical necessity?

  • Yes, eyelid surgery can become a medical necessity if you are dealing with one of the following conditions: excess skin on your eyelids interferes with your vision, herniation of orbital fat in exophthalmos, facial nerve palsy, asymmetry of the contralateral lower eyelid and post-traumatic scarring.

Does health insurance cover eyelid surgery?

  • Generally, health insurance companies do pay for the surgery if you meet the strict Medicare criteria. However, it is always a good idea to check in with your private insurance to learn more about their requirements. You may require extensive assessments, medical visits, photographs and testing to take place for approval.

What makes eyelid surgery a medical necessity?

  • Eyelid surgery becomes a medical necessity if you are dealing with one or more of the following conditions: excess skin on your eyelids interferes with your vision, herniation of orbital fat in exophthalmos, facial nerve palsy, asymmetry of the contralateral lower eyelid and post-traumatic scarring.

Do I need a medical referral to get Medicare to pay for my Eyelid Surgery?

  • Yes, you need a medical referral to get Medicare to pay for Eyelid Surgery. You can get a referral from a GP or Medical Specialist.

Do I need photographic proof to get Medicare to cover my Eyelid Surgery?

  • Yes, you do need photographic evidence to get Medicare to cover your Eyelid Surgery.

How much will my eyelid surgery cost if self-funded?

  • The cost of eyelid surgery varies drastically based on your location, experience and expertise of the surgeon, and the facility. On average, the procedure can cost from $6,000 to $13,000 AUD.

Next Steps

Always Do Your Research

  • Enquire to find out more about your surgery
  • Please read our website to learn more about your intended procedure

Do you need a Medical Referral to see Dr Turner?

  • A GP Referral is required to Consult with Dr Turner (under new AHPRA Regulations)
  • Please obtain a referral from your GP or Specialist if you want a consultation for an MBS item number surgery.
  • Please note that your Medicare Rebates will NOT be claimable without a valid recent Medical Referral

Making The Most Of Your Consultation

  • Please arrive slightly early for your in-person consultation
  • You are welcome to bring a friend or relative to help consider the information and discuss your options
  • Please be aware you may need to undress for a physical exam so wear simple clothes
  • Ensure you also take a lot of notes during the consultation and thoroughly examine all the documents provided

Want more information before scheduling your consultation?

How to Book Your Consultation

  • You can book your initial consultation by paying the $350 cosmetic consultation fee in advance – when you make your appointment

BOOK A PHONE CALL FOR MORE INFO

  • To find out more information about surgery you can book a FREE 15-minute phone conversation with our Friendly Patient Care team via Calendly- Book Consultant 1 or Book Consultant 2

Contact us or call on  1300 437 758  to arrange your surgeon consultation in Sydney.

Email us for more information:  enquiries@drturner.com.au