Does Medicare cover Otoplasty in Newcastle?

Otoplasty, sometimes called ear correction surgery, is a well-established procedure that reshapes or repositions the ears. For children and adults in Newcastle and the Hunter Valley, the decision to consider otoplasty is often linked to concerns about ear prominence, asymmetry, or congenital differences.

Dr. Yezdi Mistry, Specialist Plastic & Reconstructive Surgeon, has extensive experience performing otoplasty in Newcastle. His approach emphasises patient safety, tailored surgical techniques, and honest guidance about Medicare eligibility and costs.

What Is Otoplasty?

Otoplasty is a surgical procedure designed to modify the ear cartilage. The goal is not only to improve the ear’s position and shape but also to ensure that function and proportion are preserved. Common reasons patients consider otoplasty include:

• Prominent ears projecting further from the head than usual
• Asymmetrical ears, where one ear appears differently positioned or shaped
• Congenital variations, such as missing folds or enlarged cartilage structures
• Trauma-related changes, though these are assessed differently from congenital cases

The procedure is usually performed under general anaesthesia in accredited hospitals in Newcastle. Small incisions are made behind the ear to reshape or reposition cartilage. Stitches are typically placed to maintain the new ear position during healing.

Most patients wear a supportive head bandage for the first week, followed by a lighter dressing or headband at night to protect the ears while sleeping.

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Who Might Consider Otoplasty?

Otoplasty is suitable for both children and adults, but the reasons for surgery and eligibility for rebates differ:

• Children (5 – 17 Years): Otoplasty may be considered when prominent ears lead to teasing or difficulty fitting headwear. In this age group, Medicare rebates may apply if congenital deformities are documented.
• Adults (18+ Years): Adults often seek otoplasty for long-standing concerns. However, for patients over 18, Medicare automatically classifies the procedure as cosmetic, meaning no rebates apply.

Dr. Mistry recommends waiting until the ears are fully developed (generally by age 5 – 6) before considering surgery in children. Early correction before school years can sometimes help reduce social stress.

Medicare And Otoplasty In Newcastle

Medicare rebates are tightly restricted and apply only when strict criteria are met.

To qualify:

• The patient must be under 18 years of age
• The surgery must correct a congenital deformity (structural abnormality present from birth)
• The procedure must be billed under item number 45659 of the Medicare Benefits Schedule

If these conditions are met, Medicare provides a rebate. However, this rebate usually covers only a portion of the surgical cost. Families should still expect to pay a gap.

For adults or cases not meeting the criteria, the procedure is considered cosmetic. In these circumstances, Medicare and private health insurance will not assist with costs.

Age Restrictions For Medicare Coverage

Age is a defining factor in eligibility:

• Patients Under 18: May qualify if congenital criteria are met
• Patients Over 18: Are automatically excluded, regardless of severity

This means timing is important. Many Newcastle families choose to schedule surgery during school holidays before their child turns 18. This ensures Medicare eligibility while minimising disruption to school life.

Medical Criteria That May Qualify

Not all prominent ears meet Medicare’s definition of congenital deformity. Criteria include:

• Absence Of The Antihelical Fold – without this ridge, the ear protrudes outward
• Oversized Concha – an enlarged bowl-shaped area near the ear canal pushes the ear forward
• Deep Scapha – the hollow section of the upper ear is exaggerated

Dr. Mistry’s Newcastle practice documents these features using precise photographs and clinical notes. This evidence is essential for Medicare claims. Without it, claims are likely to be rejected.

The Medicare Item Number For Otoplasty

The relevant item number is 45659.

This item applies only to congenital ear deformities in patients under 18. Even when used, approval is not automatic. Claims are often reviewed to ensure criteria are met.

Dr. Mistry’s administrative team in Newcastle is experienced in preparing accurate submissions, reducing the chance of delays or rejections.

Understanding Gap Payments

While Medicare rebates provide some financial assistance, they rarely cover the full cost of surgery. The remaining amount, known as the gap payment, covers:

• The surgeon’s professional fee
• Anaesthetic services
• Hospital and theatre charges
• Comprehensive pre- and post-operative care

Dr. Mistry ensures families receive a detailed written quote outlining:

• The item numbers (if applicable)
• The hospital and anaesthesia fees
• The any out-of-pocket contribution

This transparency helps patients and families make fully informed decisions.

Private Health Insurance Considerations

Private health insurance may contribute toward otoplasty costs, but only if a valid Medicare item number applies. If a patient under 18 qualifies for item 45659:

• Private health funds may cover part of the hospital and theatre fees
• Policy rules vary widely, and waiting periods may apply

Dr. Mistry’s team provides the item number, estimated theatre time, and hospital codes so families can confirm coverage with their health fund.

For adult patients or cases without congenital criteria, private health insurance will not provide assistance.

When Otoplasty Is Cosmetic

For patients over 18, or for children who do not meet congenital criteria, otoplasty is classified as cosmetic.

This means:

• Medicare rebates are not available
• Private health insurance does not cover costs
• Patients are responsible for the full surgical fee

While this may feel discouraging, many patients still choose to proceed, particularly when ear prominence has caused long-term personal concern. Dr. Mistry provides a clear cost outline and ensures all questions are answered before patients make a decision.

The Otoplasty Procedure

Otoplasty typically involves the following steps:

1. Initial Consultation
   
   • Thorough medical history and ear assessment
   • Photographs and measurements for documentation
   • Discussion of goals, Medicare eligibility, and expected recovery
     
2. Surgical Planning
   
   • Selection of surgical technique based on anatomy
   • Preparation of documentation if Medicare item number 45659 applies
     
3. The Surgery
   
   • Performed under general anaesthesia in an accredited Newcastle hospital
   • Cartilage is reshaped or repositioned
   • Stitches hold the ear in its new position
   • A protective head bandage is applied
     
4. Recovery And Follow-Up
   • Most children return to school within a week
   • Sports and contact activities are restricted for 4 – 6 weeks
   • Night-time bandage use continues for several weeks
   • Follow-up appointments at Dr. Mistry’s Newcastle practice monitor healing

Why Choose Dr. Yezdi Mistry For Otoplasty In Newcastle?

• Specialist Plastic & Reconstructive Surgeon with FRACS (Plastic Surgery)
• Over a decade of surgical experience in Newcastle
• Advanced training internationally, including ear cartilage surgery
• Deep understanding of Medicare regulations and documentation requirements
• A patient-centred approach that prioritises open communication and safe outcomes

Planning Your Otoplasty Journey

When planning otoplasty, families and patients should consider:

• Timing – Surgery may be planned during school holidays to reduce disruption
• Recovery – Initial recovery takes about a week, with full activity resuming in 4 – 6 weeks
• Financial Planning – Understanding rebates, private health insurance, and gap payments helps prepare for the full cost of care

Dr. Mistry’s team provides guidance at every stage, ensuring patients feel informed and supported.

FAQs About Otoplasty In Newcastle

Arrange Your Consultation

If you are considering otoplasty in Newcastle for yourself or your child, understanding Medicare eligibility is an important first step.

Dr. Yezdi Mistry, Specialist Plastic & Reconstructive Surgeon, provides comprehensive otoplasty consultations in Newcastle. His team explains Medicare rebates, outlines gap payments, and ensures patients make well-informed decisions.

Contact our Newcastle practice on (02) 4062 7888 to schedule your appointment and discuss otoplasty options.

Further Reading

• Read more about Otoplasty
• Read more about Face
• Read Dr Mistry’s Blog on Does Medicare cover Otoplasty in Newcastle?