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Is pterygium surgery covered by Medicare?

Medicare is Australia’s publicly funded universal health care system. It provides subsidised treatment and health services to eligible Australian residents. Medicare is funded by a combination of government contributions and the Medicare levy, which is a percentage of an individual’s income. Medicare covers a range of treatments, including hospital treatments, doctor visits, diagnostic tests and some medications.

So is pterygium surgery covered by Medicare? Let’s find out. 

Does medicare cover pterygium surgery?

Pterygium surgeries are not common procedures. This procedure removes a growth from the surface of the eye, known as the conjunctiva, onto the cornea.

Medicare in Australia does cover a part of the cost of pterygium surgery. The surgery is eligible for a Medicare rebate if it is performed by a specialist ophthalmologist and the person has a Medicare card. The Medicare rebate covers the cost of the surgery, including any associated anaesthetic or hospital costs.

However, it is important to note that the surgeon’s professional fee is not covered and the patient will need to pay this out of pocket. If you choose to have glue, there will be some extra costs attached to that.

In addition, the patient is also responsible for any fees associated with any pre-operative or post-operative appointments. Patients should also be aware that some ophthalmologists will not accept Medicare and may require full payment upfront. It is therefore important to check with the surgeon before booking the procedure.

 

Kanagawa
Pterygiums are growths on the surface of the eyes that should be removed for improved vision and eye health.

Does insurance cover pterygium surgery?

Private health funds in Australia do cover pterygium treatment. Depending on the level of coverage, the cost of the surgery and associated costs may be fully or partially covered.

In order to receive the full benefit of the cover, the surgery must be performed in a private hospital or day hospital and may need to be approved by the insurer.

Coverage may include hospital costs, surgeon’s fees and anaesthetist’s fees, as well as any follow-up care and treatment. It is important to check with the insurer to determine the exact level of coverage. If you are in top level cover with your health insurer, the cost of admission to hospital, consumables and the anaesthetist fee may be fully covered. Surgical fees usually involve a gap.

 

Kanagawa
Pterygiums are growths on the surface of the eyes that should be removed for improved vision and eye health.

If you would like to book an initial consultation with Vision Clinic Sydney to find out more about pterygium surgery, the fees charged and the Medicare and health insurance payments, contact us today.

Points to remember about pterygium surgery and Medicare

  • Medicare does typically cover part of pterygium surgery
  • The surgeon’s professional fee is not covered by Medicare and the patient will need to pay for that

Frequently Asked Questions

Below you can find our most frequently asked questions: 

How much does pterygium removal cost in Australia?

The cost of pterygium removal in Australia can vary depending on the complexity of the procedure and the region you are in. Generally, the out-of-pocket cost of the procedure can range from around $500 to $1000, with some private clinics charging up to $3000. 

What is the Medicare benefits schedule item number for pterygium?

The Medicare item number for pterygium excision is 42686 and the item number for the conjunctival autograft is 42641. 

Does Medicare pay anything toward pterygium surgery?

Medicare covers some of the cost of pterygium surgery for public patient in Australia. Medicare rebates are available for the surgical and on-site fees associated with the procedure.

The rebate amount is determined by the Medicare Benefits Schedule (MBS) fee for the procedure. However, patients are still responsible for any remaining costs not covered by Medicare. 

Will a private health insurer in Australia cover a pterygium surgery cost?

It depends on the specific health insurance plan. Generally, most private health insurance plans cover at least a portion of the cost of pterygium surgery. It is best to check with your insurer to determine the exact coverage for your plan. 

Does Medicare cover pterygium surgery 100%?

No, Medicare does not cover pterygium surgery 100% in Australia. The Medicare Benefits Schedule (MBS) covers part of the cost of the surgery, but there may be additional costs that are not covered. Patients may need to pay a gap fee to the ophthalmic surgeon performing the procedure. 

Will my private health insurance cover the full cost of pterygium surgery or will I be liable for any out-of-pocket expenses?

It depends on your private health insurance plan and the specific procedure you are having done. Generally speaking, most private health insurance plans will cover part of the cost of pterygium surgery, however, you may be liable for some out-of-pocket expenses depending on the specifics of your plan.

It is best to contact your insurance provider directly to find out exactly what your coverage is.

This information is not intended to be used for diagnosis or treatment. It is aimed at presenting a perspective only and is not a substitute for a prescription. Anyone experiencing a medical condition should consult their doctor.:

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