Upper blepharoplasty is sometimes covered by Medicare, but only under specific circumstances.
While the procedure is commonly associated with cosmetic surgery, it can also be performed for functional reasons, such as when excess eyelid skin obstructs the upper field of vision.
The Medicare Benefits Schedule (MBS) does allow cover for upper blepharoplasty, however, eligibility depends on strict criteria being met and appropriately documented.
This blog will walk through the circumstances in which Medicare may cover the procedure, how eligibility is determined, what evidence is required, and how this affects the overall cost. Essentially, eligibility needs to be assessed on a case-by-case basis, as every patient will have differing needs and reasons for undergoing the procedure.
Understanding how Medicare works for upper eyelid surgery
Medicare does not provide cover for procedures that are considered cosmetic only. For upper blepharoplasty to be eligible for a Medicare rebate, it must be considered medically necessary.
Medical necessity for the procedure usually means that the upper eyelid skin is physically affecting your ability to see. The most common situation where this might apply is when excess upper eyelid tissue causes hooding to a level that interferes with your vision, making activities like reading or driving more difficult.
In order for Medicare to provide a rebate for the surgery, the procedure must meet the criteria listed under MBS item number 45617. This item applies to upper eyelid surgery when the eyelid heaviness is causing obstruction to the visual field or impacting normal function of the eyelid. It also applies when there is redundant skin that rests on the eyelashes.
The distinction between a cosmetic or medical need for the procedure can be assessed by your GP and your surgeon, and needs to be supported by clear documentation as evidence.
What to expect at your consultation
During your consultation with an experienced surgeon, you will be assessed for any functional concerns related to the upper eyelids.
An assessment may involve a physical examination to evaluate the amount of excess skin present and where it sits in relation to the lash line or pupil. If the skin rests on the lashes or drops over the edge of the eyelid, and this is contributing to visual obstruction, you may be considered a suitable candidate for Medicare cover.
Your surgeon may also ask questions about symptoms like visual fatigue, brow strain, or difficulty keeping the eyes open when reading. However, the most relevant part of this assessment will be clinical evidence showing functional interference.
You will also be able to discuss the steps of the Medicare process in further detail, as well as ask your surgeon any questions you have. Your consultation should be an efficient and informative step in your journey, providing you with the information you need to make an informed decision about whether or not to proceed with the surgery.
How an upper blepharoplasty Medicare rebate affects the overall cost of the procedure
If the reason for undergoing your procedure falls under medical necessity and is eligible for Medicare under item 45617, a portion of your fees may be reimbursed by Medicare. However, this rebate is typically only a certain percentage of the overall cost, and may not be able to cover the entire cost of the procedure.
Like many surgical procedures, costs don’t necessarily come down to one single factor – in fact, costs need to consider different components of the surgical journey, such as the surgeon’s fees, anaesthesia fees, and hospital or facility fees.
Surgeons (or their team) will typically provide a detailed cost breakdown during your consultation, detailing where each fee is coming from. Medicare’s rebate amount may cover specific components of the costs, but not the full amount.
As for facility or hospital fees, your private health insurance provider may be able to provide assistance – however, this will depend on your level of cover, and where your procedure will be performed. If you think your provider may be able to assist with an additional portion of the costs, it’s important to contact them directly before proceeding with your surgery to confirm your level of cover and any terms and conditions that may apply.
Getting a referral and planning the next steps
If you suspect that your upper eyelid concerns are causing issues with vision, you’ll need a referral from your GP to see a surgeon.
Once you’ve had your initial assessment, your surgeon will discuss whether or not you meet the MBS criteria for upper blepharoplasty under item 45617. If you do, the procedure can be planned with the necessary supporting evidence in place. If not, they will still discuss your options with you, but the financial arrangements will then typically need to be based on a cosmetic procedure.
Your surgeon can go over the application steps and help to prepare you for the next steps in the process. You’ll also be able to discuss what to expect should you not be eligible for the rebate.
Apart from costs and Medicare eligibility, your consultation with your surgeon will also provide you with guidance on procedure preparation steps, post-operative care, and activity restrictions in the weeks after surgery. The aim is to provide you with the time to answer any and all of your questions, leaving you feeling well informed of the process and equipped to make a personal decision about undergoing the procedure.
Our Specialist Plastic Surgeon at Rodin Clinic Perth: Dr Robert Choa
If you would like to have your eligibility for upper blepharoplasty Medicare cover assessed, you will need to have an in-person consultation with a surgeon after receiving a referral from your GP.
Your surgeon will carefully examine the condition of your upper eyelids and perform an assessment to see if you may meet Medicare’s eligibility requirements. You will be able to discuss the next steps if you do meet the criteria, as well as the possible options should your procedure be considered cosmetic only.
If you have any questions or need guidance on how to arrange your consultation, please get in touch with our team at Rodin Clinic in Perth. You may fill out our online form, email us at reception@rodinclinic.com.au or call us at 08 9389 9522.