Can I claim my Nose Surgery on Medicare?

Nose surgeries are one of if not the most commonly performed plastic and cosmetic surgery procedure. However, despite its popularity patients often send us inquiries due to ambiguities of whether or not nose surgery procedures are covered by Medicare and/or private health insurance. There is no simple yes or no answer, unfortunately, its more complicated than that. This is why we have collated the following information. We believe it is important to inform our patients on what determines a particular procedure as eligible for partial and full funding. As well as who can apply for the rebates.

Will Private Health Insurance (PHI) cover Nose Surgery?

nose-job.

In order to claim Nose Surgery using your private insurance, you must first be eligible for the Medicare item number.

However, as almost every private health insurance company has its own terms and policies, we advise that you communicate directly with them in order to get more information about funding and funding conditions.

In certain cases, it is possible to apply for Early Release of Super Funds for Nose surgery. But, in order for this to occur, you must comply with certain government rules, and even then it does not guarantee a fund release, especially in the cases when the surgery is requested for aesthetic reasons.

Popular Reasons for wanting to have Nose Surgery

The nose is one of the most complex organs. In addition to giving or disturbing the harmony of our face, it also has a very important function – breathing and smelling.

While most other aesthetic problems can be “covered” to some extent, the nose despite makeup and non-invasive procedures is an unsolvable problem for people that are not happy with its appearance. In addition to causing dissatisfaction, the nose can also be a source of many problems that can negatively affect a person’s quality of life.

As a result, the reasons for nose surgery are divided into two categories: Aesthetic and functional.

Aesthetic Reasons for Nose Surgery

Aesthetic reasons such as changing the size, curvature, width, and/or shape are the most common reasons patients elect to have the surgery.

For example, patient feel their nose is either;reasons-men-nose-shapes-plastic-surgery

  • Crooked, as a result of an injury or congenital condition
  • has a tip that is wide, thickened, or lowered.
  • has a hump on the dorsum
  • Alternately the nose is simply either;
    • Too long or too short
    • Too wide or too narrow
  • Or the have nostrils that are oversized, undersized, or asymmetrical.

Functional Reasons for Nose Surgery

In addition to external deformation, there are also deformations of the internal structures of the nose that cause difficulty breathing.

Difficulty breathing through the nose can cause:

  • Headaches
  • A feeling of tiredness
  • A weakened sense of smell
  • Resonance disorder
  • Painful and difficult swallowing
  • Bad sleep
  • Snoring
  • Inability to play sports or do physical activities

…and many more!

Coco Ruby Blog - Before and After Nose Surgery on Medicare Banner Image

How Do I Qualify for the Medicare Rebate?

Medicare dictates that, as with other procedures, strict requirements must be met in order to apply for rebates for Nose Surgery.

The Medicare Benefits Schedule (MBS) uses the categorization system as a list of all interventions that the Australian Government subsidies in a certain percentage or in full.

Nose Surgery or more specifically Rhinoplasty and Septoplasty, fall under the third category of procedures – therapeutic procedures, and a subgroup of Ear, Nose, And Throat Surgery.

The corresponding MBS codes are:

41671 – NASAL SEPTUM, SEPTOPLASTY, SUBMUCOUS RESECTION or closure of the septal perforation

41672 – Reconstruction of the nasal septum

45635 – Rhinoplasty, partial, involving correction of the bony vault

45641 – Rhinoplasty, total, including the correction of all bony and cartilaginous elements of the external nose, with or without autogenous cartilage or bone graft from a local site

45644 – Rhinoplasty, total, including the correction of all bony and cartilaginous elements of the external nose involving autogenous bone or cartilage graft obtained from a distant donor site, including obtaining of graft

Full MBS Item Number breakdown and description:

41671 – NASAL SEPTUM, SEPTOPLASTY, SUBMUCOUS RESECTION or closure of the septal perforation. Benefits are payable for septoplasty (item 41671) where performed in conjunction with rhinoplasty. Full clinical details must be documented in patient notes, including pre-operative photographic and/or NOSE Scale evidence demonstrating the clinical need for the service as this may be subject to audit.

41672 – Reconstruction of the nasal septum

45635 – Rhinoplasty, partial, involving correction of bony vault only, if:

  • the indication for surgery is:
    • airway obstruction and the patient has a self‑reported NOSE Scale score of greater than 45; or
    • significant acquired, congenital or developmental deformity; and
  • photographic and/or NOSE Scale evidence demonstrating the clinical need for this service is documented in the patient notes

45641 – Rhinoplasty, total, including the correction of all bony and cartilaginous elements of the external nose, with or without autogenous cartilage or bone graft from a local site (nasal), if:

  • the indication for surgery is:
    • airway obstruction and the patient has a self‑reported NOSE Scale score of greater than 45; or
    • significant acquired, congenital or developmental deformity; and
  • photographic and/or NOSE Scale evidence demonstrating the clinical need for this service is documented in the patient notes

45644 – Rhinoplasty, total, including the correction of all bony and cartilaginous elements of the external nose involving autogenous bone or cartilage graft obtained from a distant donor site, including obtaining of graft, if:

  • the indication for surgery is:
    • airway obstruction and the patient has a self‑reported NOSE Scale score of greater than 45; or
    • significant acquired, congenital or developmental deformity; and
  • photographic and/or NOSE Scale evidence demonstrating the clinical need for this service is documented in the patient notes

For more information, you can download our Medicare and Health Insurance Guide!

Coco Ruby Blog - Free Medicare and Health Insurance Guide Download

Will Medicare Cover Nose Surgery for medical reasons?

The official rule of all private health insurance providers and Medicare is that procedures aimed at aesthetic beautification cannot apply for and obtain financing.

Unfortunately, all cosmetic procedures performed on the nose fall into this category. However, if your nose presents with problems that negatively affect your breathing, and thus impair the quality of your life, it is possible that Medicare will finance a percentage of your procedure. An intervention to eliminate these negative effects must be medically justified and necessary.

Special criteria for nose surgery describe:

  • A Medicare benefit for items 45632 – 45644 and 45650 is payable where the indication for surgery is for airway obstruction and the patient has a self-reported NOSE Scale score of greater than 45, or significant acquired, congenital or developmental deformity.
  • The NOSE Scale, Nasal Obstruction Symptom Evaluation, is an instrument that helps determine the severity of the obstruction.
  • It contains 5 categories in which patients rate the severity of the following problems on a scale of 1 to 5:
    • Nasal congestion and stuffiness
    • Nasal blockage and congestion
    • Trouble breathing through the nose
    • Trouble sleeping
    • Inability to get enough air during the exercise or exertion
  • Full clinical details must be documented in patient notes, including pre-operative photographic and/or NOSE Scale evidence demonstrating the clinical need for the service as this may be subject to audit.

If the result on the NOSE test is less than specified in the MBS regulations, or if the main reason for the application is the desire for aesthetic beautification, Medicare and PHI will reject the request for funding.

Research to find out if Medicare and the MBS Covers Your Nose Surgery Procedure

  • You can download a complete MBS benefits scheme to find out more about the categorization, codes, and conditions for each procedure.
  • If you are looking for a specific procedure, you can use a built-in search function to browse through the categorization faster
  • If the desired procedure is not listed in the MBS categorization, Medicare is not offering reimbursement for that specific surgery

Thinking about getting Nose Surgery? Download the Nose Surgery guide!

Coco Ruby Blog - Ultimage Guide to Rhinoplasty Surgery 2021 Nose Surgery Guide

Why is Medicare for Nose Surgery confusing a lot of patients seeking Plastic or Cosmetic Surgery?

Every nose is different, and if we take into account the complex construction of the nasal airways, it is clear that the nose requires an individualized surgical approach. Accordingly, most patients deal with different types and intensities of problems caused by nasal obstructions. When applying for nose surgery financing, it is difficult to prove and measure the extent to which these problems affect a person’s daily life. Medicare and private health insurance providers are therefore very strict in their assessment and require that all conditions must be met in order to respond affirmatively to a request for rebates. The basic condition that disqualifies most claims is that only procedures that are medically justified can be applied in the process. But if you manage to prove the medical justification and need for the procedure you are requesting, Medicare and private insurance providers will most likely comply with your request.

Life-Changing Effects of Nose Surgery

Nose surgery is one of the most demanding procedures in plastic surgery. Nose surgeries, whether aesthetic or functional, can make life easier for patients who suffer from low self-esteem, difficulty breathing, and other problems caused by various nasal obstructions. The reason for deciding on this procedure is most often dissatisfaction with the nose with which the patients were born or a change in appearance that occurred during ageing. Other cases are usually related to injuries that have contributed to the distortion of the nose or are aimed at improving breathing. Most patients, whether they opt for rhinoplasty, septoplasty, or septorhinoplasty, report an increase in self-esteem and improved quality of life.

To view more before and after images, you can visit the Nose Surgery photo gallery here.

Coco Ruby Blog - Before and After Nose Surgery Sample Gallery Image

Medicare Rebates are subject to change and review

MBS Item codes can change or be eliminated from the Medicare rebate schedule. If your surgery is currently eligible for a Medicare rebate, it may be best to perform your procedure sooner rather than later.

Top Tips for dealing with Medicare regarding your claim

  • It is important that you understand the difference between cosmetic and plastic surgery. Cosmetic surgery procedures can never apply for rebates
  • Plastic Reconstructive Surgery procedures are medically justified and necessary
  • Medicare and private health insurance providers usually partially fund surgical interventions, and almost never fully
  • If you have private health insurance, ask your insurance provider about the services and how they differ from Medicare
  • Be specific and precise in your request
  • Since MBS descriptions and classifications are subject to almost daily changes, it is important to be up to date
  • Throughout the rebate application process, it is important to document every step of the way
  • Learn MBS codes and try to fully understand the descriptions
  • Learn what the terms “medically indicated” and “Statement of benefit” refers to

Further Tips For Claiming Your Nose Surgery

The process of applying for rebates for nose surgery begins with a consultation.

  • Ask for a written trace of all correspondence from the first moment, including consultations.
  • When choosing a plastic surgeon, it is important to opt for a professional plastic surgeon, not a cosmetic surgeon who operates in the office.
  • General Practitioner referrals are valid for 12 months,
  • While a specialist referral is valid for only 3 months. Be quick so that you do not run the risk of passing these deadlines.
  • Sign up for just one procedure since combining procedures usually results in the rejection of the request.

When phoning Medicare and Health funds australia-health-fund-insurance-changes-policy-2019-gold-silver

  • Get ready! Applying for rebates can be a stressful and time-consuming process
  • Call, but don’t overdo it!
  • Use email to easier document every step of your process
  • Ask for written documentation
  • Keep all the documents ready and safe

Unfortunately, CocoRuby doesn’t provide assistance with Medicare or Health Fund processing.

This is solely the patient’s responsibility.

However, we do list the Medicare code(s) on your Quote and on your Invoice(s). So, if you are eligible for a Medicare rebate code or health fund rebate, this can help you when it comes to submitting your paperwork.

More Information about Your Procedure

You can Download  Free Procedure Guides on your chosen surgery.

Also, our FAQs page might help you find out more about the procedure you are interested in, and other patients’ experience.

For more information about pricing and payment methods, please visit our page on Surgery Payment options.

You can also talk to our Patient Care Team from 8 am – 6 pm Monday to Friday on 1300 264 811

Phone 1300 264 811 or send us an enquiry form, below.

*Disclaimer: Individual results can vary significantly from patient to patient. The information we provide is general.  For further information on what to expect for your preferred procedures, arrange to see one of our Specialist Plastic Surgeons for a full-history and surgical consultation. Read further information about surgical outcome variability on our Disclaimer page.

Source: cocorubyplasticsurgery.com.au

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