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Question of the week: changes to the blepharoplasty item number

My heavy eyelids make it hard for me to see, especially when I’m tired. I often find myself raising my eyebrows to try and elevate my lids. I’ve heard that Medicare’s recent changes mean that I might not be covered by my private health insurance for this procedure anymore. How have the rules changed, and can it be done under local anaesthetic in your clinic, if my fund won’t cover surgery in hospital?
- patient

blepharoplasty eyelid surgery Brisbane surgeon

above: before and three months after blepharoplasty surgery with Dr Sharp

Dr David Sharp, plastic surgeon in Brisbane, profile image

Dr Sharp:

Up until the 1st of November 2018, if you had loose eyelid skin that rested on your eyelashes (when looking straight ahead), your procedure met the Medicare Benefit’s Schedule item number criteria for a ‘medically required’ blepharoplasty, as Medicare deemed that the procedure was required to improve your vision.

Medicare recently decided that the current criteria wasn’t adequate, and as of last week, the item number criteria was revised. It no longer relies upon only the plastic surgeon’s assessment of the patient, so if you wish to access Medicare rebates or use private health insurance cover, you now also have to make an appointment with an optometrist or opthalmologist to undergo examination and have obstructed vision confirmed, before undergoing surgery with the plastic surgeon.

If you think this applies to you, mention this when you book your consultation, so we can provide you with a referral letter to an optometrist or opthalmologist explaining why you require the examination and report. Once this occurs, we can determine your rebates and out of pocket costs.

So what do out of pocket costs for blepharoplasty surgery look like now?

If you don’t have private health insurance:

If you still meet the MBS criteria for a ‘medically required’ blepharoplasty, Medicare will rebate a portion of your surgeon’s and anaesthetic fee, and you will be 100% out of pocket for your hospital fee. If this is the case, the procedure will cost you about $3,500-$4,000 out of pocket (after rebates). If you don’t meet the new criteria, your costs will total around $5,000.

If you have private health insurance:

If you still meet the MBS criteria for a ‘medically required’ blepharoplasty, Medicare and your private fund will cover your hospital fees (minus any excess payable on your policy) and will rebate part of the surgeon’s and anaesthetic fees. The procedure will cost you about $2,300-$3,000 out of pocket (after rebates). If you don’t meet the new criteria, your costs will total around $5,000.

Should a blepharoplasty be performed in hospital under general anaesthetic, or in surgeon’s rooms under local anaesthetic?

I mostly perform this procedure under general anaesthesia in hospital. This ensures that the patient is not subjected to any unnecessary discomfort, and more extensive blepharoplasty techniques (where muscle or fat can be repositioned) can be utilised without compromising your operative experience. That said, some blepharoplasties can be comfortably performed under local anaesthetic, and this is certainly a possibility for some patients. It’s one of the considerations we discuss together during the initial consultation.

Blepharoplasty under local anaesthetic in your surgeon’s rooms might sound like a convenient, cost effective solution, but it comes with its own risks. The best location for your surgery should be a multifactorial decision made between you and your surgeon, based on your individual circumstances and procedure.

If you’re considering blepharoplasty surgery and want to know how the MBS item number changes specifically impact your procedure, please call our helpful patient care team on 07 3202 4744.

Please note: the fees provided in this article are only indicative and may vary. When you book a consultation with Dr Sharp, we will check your eligibility for this procedure with your health fund, so if you qualify for the item number coverage, we will be able to supply you with a complete quote (inclusive of all rebates) at the time of your consultation.

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