Medicare for Blepharoplasty – Will Medicare cover Eyelid Surgery?

Will Medicare Cover My Blepharoplasty?

Blepharoplasty, commonly referred to as eyelid surgery, is a popular procedure in Australia for both cosmetic and medical reasons. While many people undergo blepharoplasty to change their appearance, others require it to correct functional issues that impact their vision or overall eye health. If you’re considering this procedure, one of the first questions that may come to mind is whether Medicare will cover the cost.

Blepharoplasty: Is It Right for You?

Blepharoplasty is a surgical procedure designed to remove excess skin, muscle, and sometimes fat from the upper and/or lower eyelids. The procedure can change the appearance of the eyes by making them appear more alert, and in some cases, it can restore proper vision that has been obstructed by lax or excess skin.

There are two main types of blepharoplasty:

• Upper eyelid blepharoplasty: This focuses on removing excess skin and fat from the upper eyelids.
• Lower eyelid blepharoplasty: This targets the removal of bags or puffiness under the eyes.

People seek blepharoplasty for various reasons, and these can generally be classified under two categories: cosmetic and medical.

Cosmetic Reasons:

• To reduce the appearance of droopy or puffy eyelids
• To achieve a more awake look
• To correct asymmetry between the eyelids
• To remove “baggy” lower lids or excess skin

Medical Reasons:

• Lax upper eyelid skin obstructing vision
• Chronic irritation from excess skin rubbing against the eye
• Difficulty wearing glasses or contact lenses due to excess skin around the eyes
• Fatigue from constantly trying to raise the eyebrows to improve vision

Now, while cosmetic blepharoplasty is not covered by Medicare, medical blepharoplasty may be partially or fully covered if it meets certain criteria.

Can Your Blepharoplasty Be Covered by Medicare?

Medicare is Australia’s public healthcare system, providing subsidies for a wide range of medical procedures. However, it’s important to understand that Medicare distinguishes between cosmetic and medically necessary procedures. Cosmetic procedures are generally not covered by Medicare, whereas medically necessary procedures may be eligible for coverage.

The main difference between a cosmetic procedure and a medically necessary procedure lies in the reason for undergoing the surgery. If you are seeking blepharoplasty purely for aesthetic reasons this would be considered a cosmetic procedure. Cosmetic procedures are not covered by Medicare.

On the other hand, blepharoplasty may be seen as a medically necessary procedure if it is required to improve your health or quality of life, such as when the heaviness of your eyelids interferes with your vision.

Medical Necessity – When Abdominoplasty Becomes More Than Cosmetic

There are several health-related issues that may make blepharoplasty a medical necessity. Some of these include:

• Visual Field Obstruction: Excess skin on the upper eyelids can hang down and block your peripheral vision, making it difficult to see clearly.
• Chronic Eyelid Irritation: If your excess skin rubs against the surface of your eye, it can cause irritation, discomfort, and even infections.
• Difficulty Performing Daily Tasks: When eyelid laxity becomes severe, they may impede your ability to perform everyday tasks such as reading, driving, or working.
• Strain and Discomfort: Constantly raising your eyebrows to lift heavy lax eyelids can lead to forehead strain and headaches.

To qualify for Medicare coverage, your blepharoplasty must meet specific medical criteria. These criteria are outlined under the Medicare Benefits Schedule (MBS), which is the list of services covered by Medicare.

The main criterion is that the procedure must address a functional impairment. In most cases, this means that your eyelids must be obstructing your vision or causing significant discomfort. To prove this, you will need documentation from a specialist—such as an ophthalmologist or plastic surgeon—stating that blepharoplasty is necessary for medical reasons.

MBS Item Numbers for Blepharoplasty

Medicare has specific MBS item numbers that correspond with medically necessary blepharoplasty procedures. As of the latest guidelines, the following item numbers are relevant:

Item 45617

This item covers upper eyelid reduction for medical conditions such as visual impairment, inflammation, herniation of orbital fat, or post-traumatic scarring. Symmetry restoration for the contralateral eyelid may also qualify. Photographic or diagnostic imaging evidence must be documented to demonstrate clinical need.

Key points:

• For conditions like visual obstruction or inflammation.
• Clinical evidence required.
• Fee: $267.80 (75% benefit = $200.85; 85% benefit = $227.65).
• Multiple Operation Rule applies.
• Requires anaesthesia.

Item 45620

This item covers lower eyelid reduction for medical conditions such as herniation of orbital fat in exophthalmos, facial nerve palsy, or post-traumatic scarring. It may also include restoring symmetry in the contralateral eyelid. Clinical need must be documented through photographic or diagnostic evidence.

Key points:

• For conditions like herniation of orbital fat or facial nerve palsy.
• Clinical evidence required.
• Fee: $371.45 (75% benefit = $278.60; 85% benefit = $315.75).
• Multiple Operation Rule applies.
• Requires anaesthesia.

These item numbers dictate whether your surgery qualifies for a Medicare rebate. Dr Mark Kohout will help determine if your condition fits the requirements associated with these MBS codes.