Blepharoplasty & Medicare rebates with Dr Naveen Somia

Trish Hammond: I’m here today with Dr Naveen Somia, who’s a specialist plastic surgeon practicing out of Bella Vista New South Wales in Sydney.

Naveen: And Bondi Junction.

Trish Hammond: And Bondi Junction as well. And Bondi Junction. We’re going to have a bit of a chat about blepharoplasty. It’s one of the procedures that he’s renowned for, and we’re going to sift through a bit of the Medicare information for you as well. Thank you so much for taking the time today.

Naveen: Thank you, Trish.

Trish Hammond: Tell us a little bit about the blepharoplasty and Medicare. I have a lot of people who contact me. They’ve been to the doctor. They’ve got to go and see someone to get their eyes fixed, and they’re like, who do I go to and what am I going to be covered for? Shed a bit of light for us, would you?

Naveen: Yeah. Blepharoplasty, or upper eyelid surgery is viewed as functional if it meets certain stringent criteria. The stringent criteria are such that if the eyelid is malpositioned or there’s an abnormality of the eyelid, or there’s an abnormality of the excess eyelid skin that actually covers some of your field of vision. It is not just a cosmetic appearance thing. It has a functional importance as well, because an impaired vision is always a functional limitation to the patient. These are two conditions, and of course if you have a droopy eyelid as well.

These are two conditions where the blepharoplasty, or upper eyelid surgery, is viewed as medical as opposed to cosmetic, and hence will attract some Medicare benefits; which in turn will mean that if you are covered with the Private Health Fund, depending on the level of your cover, you may get some private health cover, which will enable you to have this operation in a private hospital with some financial benefits.

Eyelid operations that are done for repairing cancer defects, trauma defects, or treating eyelid conditions due to any congenital deformities, are obviously viewed as functional, not cosmetic, hence they do attract medical benefits. Conditions like inward turning or outward turning of the eye like what’s known as entropion or ectropion also attract Medicare benefits because they are viewed as functional as opposed to cosmetic.

Lower eyelid is never functional, unless it has either entropion or ectropion, or is a cancer or trauma defect. Ageing of the lower lid does not attract any medical benefits. It’s viewed as a purely cosmetic operation.

Trish Hammond: Got it. If your skin is very loose on top and you can’t see and you’ve got a problem with your vision, that is classified as having an item number, but the bottom definitely nothing ever. All right. Great. So, with an item number, if someone comes to see a specialist plastic surgeon, they’re not covered for the, what are they actually covered for?

Naveen: A medical item number means that Medicare recognises that this condition is non-cosmetic and hence medical, so, if in the event of you having an operation in a private hospital, provided you have private health cover, your hospital cost gets covered to the extent your fund will cover you. The other factors involved in the cost are your surgical fee and your anaesthetic fee, which vary from provider to provider, and that is something that you can find out when you go to see your specialist surgeon. Medicare has a small amount of payment for that and there’s invariably a gap, which will depend on your surgeon.

Trish Hammond: Okay, great. Excellent. Basically, if you’ve got private health cover, you’re going to get covered for that portion of the hospital and a portion of the anaesthetist hopefully, and you just pay the gap between the Medicare rebate and surgeon’s fee.

Naveen: That’s correct.

Trish Hammond: Great. Awesome. Hopefully that’s cleared it up for you as well.

Naveen: Thank you.

Trish Hammond: If you’re instantly looking for a bleph, don’t go past Dr Somia, and if you’ve got any questions, or if you want a bit more information, drop us an email at [email protected]. Thank you so much.

Naveen: Thank you, Trish. Thank you for having me.

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