Will Medicare and my Health Insurance Cover my Breast Reduction Surgery?
Breast Reduction Surgery is one of the very few breast surgery procedures that your private health insurance and Medicare will cover. However, you will most likely still have out of pocket costs. Generally you will be covered for some or all of your hospital costs, and a small contribution will be made to the medical costs (Surgeon, Anaesthetist, Assistant). Why is that the case? There are often a number of reasons for considering getting a Breast Reduction Surgery, including:
- Relief from back, neck and shoulder pain caused by the heaviness of the breasts
- Relief from chronic skin infections under the breasts (‘intertrigo’)
- As well as, wanting to rectify other breast-weight related health conditions that affect the quality of living, for example going to the gym, and jogging.
Will Medicare cover my Breast Reduction?
- Having heavy breasts that cause chronic health conditions constitutes a medical reason for having breast reduction surgery.
- If the surgery is deemed by your surgeon to be medically necessary and meets strict Medicare criteria, a rebate should be granted.
- You should first attend your GP to request a medical referral to your Specialist Plastic Surgeon
Potential Outcomes of Breast Reduction
- Breast Reduction surgery may prevent or treat recurring problems related to heavy breasts.
- Breast Reduction surgery may alter the patients’ lifestyle – this ranges from better sleep to being able to participate in new activities e.g. fitness classes which they have been unable to attend in the past.
In order to claim your surgery on Medicare
You will need a Medical Referral in order to claim your surgery with Medicare. To be eligible to Claim a Medicare item number for your breast reduction surgery, (as with any other Medicare rebate), visit your GP and ask for a referral to your surgeon or phone Coco Ruby Plastic Surgery on (03) 8849 1400 to find out more about Breast Surgery including Reduction Mammoplasty.
You can also register to attend a Coco Ruby EVENT night to learn more about your specific surgery options.
Will Medicare cover my Breast Reduction Plastic Surgery?
For a Reduction Mammoplasty – YES – Medicare Rebates MAY apply – but strict criteria must be met. There is no guarantee, but ask your General Practitioner for information to see if you qualify or speak with a Specialist Plastic Surgeon after getting a referral from your GP.
Why is the Medicare Rebate Question for breast surgery so confusing?
The answer to this question is often confusing for patients seeking cosmetic surgery. This is due to the variables of the situation and depends on the patient and the procedure required.
Medicare will sometimes offer a minor rebate on some procedures. However, rebates are generally available only for reconstructive plastic surgery. In other words, a surgery that is deemed ‘essential’. While not all breast surgery falls under this category, Breast Lift (Mastopexy) and Breast Reduction MAY fall under this category for many patients.
When it comes to Plastic & Cosmetic Surgery, the Medicare REBATE guidelines are very clear; Medicare will not cover ‘non-therapeutic cosmetic surgery’ NOR ‘non-therapeutic plastic surgery’ procedures. Significant Breast Ptosis after pregnancy and chronic Back Pain or Skin Infections related to large breasts are chronic medical conditions, however, and may lead to eligibility for a minor rebate.
Breast Reduction Surgery and the Medical Benefits Scheme (MBS)
If you meet the current Medicare criteria and required documentation proof for your Breast Reduction Surgery, then yes, you may qualify for a small rebate from Medicare for your procedure. MBS changes at the end of 2018 included additional photographic proof, examination evidence/reporting documentation and stricter patient criteria for Medicare rebates for Breast Reduction Surgery.
Will Private Health Insurance cover Breast reduction?
Additionally, you may be eligible for surgery cover from your Private Health Insurance provider. This will, however, only apply if your condition meets the criteria for a Medicare item code/MBS rebate. You will need to check directly with your Health Fund regarding your policy. It’s important to recognise that Medicare codes and rebate eligibility criteria for Breast Reduction Surgery are subject to review and can change with very little notice. Therefore, you should discuss your eligibility with your chosen Specialist Plastic Surgeon as they will have the most up-to-date information on hand.
There are often crucial medical and health reasons that lead women to seek Breast Reduction Surgery, these may include:
- Chronic skin infections.
- Excess perspiration around or under breasts.
- Difficulty purchasing bras and other items of clothing.
- Challenges when exercising caused by large, pendulous breasts.
- Back pain, neck pain or shoulder pain related to breast weight, breast volume or breast ptosis.
- Other breast-weight related health conditions that impact your health.
If you are suffering from one or more of the above symptoms due to your breast weight or volume, your Breast Reduction surgery may be eligible for a rebate. However, you will need to meet a strict number of criteria. Click here to view an in-depth outline of the MBS criteria for 45523 Breast Reduction Surgery.
45523 Item Number Criteria
Reduction mammaplasty (bilateral) with surgical repositioning of the nipple: (a) for patients with macromastia and experiencing pain in the neck or shoulder region; and (b) not with insertion of any prosthesis
If I am not eligible for a Medicare rebate, will my private health fund cover my breast procedure?
- Private Health Funds only cover a procedure if; it has an MBS item number and the patient meets current Medicare eligibility criteria.
- You will, therefore, need to meet the criteria for a Medicare rebate in order to seek cover from your Health Fund.
- Extensive documentation, examinations, imaging or volumetric testing, and photographs may also be required.
If Medicare or a Health Fund do not cover my breast reduction, how much will my procedure cost?
- The cost of having a Breast Reduction performed by a Plastic Surgeon in Melbourne will vary. This is due to the fact that each procedure is fully customised to meet your specific needs and desired surgical outcome.
- Our team can help you assess your eligibility for coverage by MBS or your health fund. They can also assist you in understanding the cost and risks of surgery.
Read more about the Risks of Breast Reduction Surgery (Reduction Mammoplasty) To access your eligibility to claim a Medicare rebate for your Breast Reduction Surgery, visit your GP or other specialist and ask for a referral to one of our Specialist Plastic Surgeons. You can also speak to our knowledgable Patient Care Team, who are available to answer your questions. Phone us on (03) 8849 1400.
Can I use my Super Fund for Breast Reduction Surgery?
Some patients may consider requesting an early release of Super funds to help pay for Breast Reduction surgery. However, before doing so, it is important to note that:
- Each application for early Super release is assessed on an individual basis.
- Tax implications apply so seeking professional financial advice is recommended.
- Superfund withdrawal applications can be made through your MYGOV account via the ATO. As of July 2018, the ATO makes decisions about early-super-release applications within about 14 days of your application being received.
Our Breast Reduction Plastic Surgeons in Melbourne include:
- Dr Craig Rubinstein – MBBS, FRACS (Plast) – Specialist Plastic Surgeon,
- Find out more about:
Considering Breast Reduction Surgery? Download Our Breast Reduction Guide
