Will Medicare cover my Breast Implant Removal?

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Can I claim my Breast Implant Removal on Medicare?

Patients interested in Breast Implant Removal often send us inquiries regarding the coverage of this procedure by Medicare and other health insurance providers. Unfortunately, there is no straightforward answer to this question, at least not one that would apply to all patients. In order for Medicare to cover the cost of the Breast Implants Removal procedure, there are certain conditions that must be met.

Will Private Health Insurance (PHI) cover Breast Implant Removal?

In order to claim your Breast Implant Removal using your private insurance, you must be eligible for the Medicare item number. If you are not eligible for a Medicare care number you will not be eligible for PHI cover either.

Moreover, if you are eligible for cover, it is important to be aware that you will still have out of pocket costs. The amount of cover can be dependent on your insurance provider as well as your level of coverage and other factors.  We advise you to communicate directly with your insurance company.

In certain cases, it is possible to apply for Early Release of Super Funds for Breast Implant Removal surgery. However, this process requires compliance with certain government rules and does not guarantee a fund release.

Popular Reasons for wanting to have Breast Implant Removal

As the name suggests, Breast Implant Removal is a surgical procedure that removes breast implants. The reasons for removing breast implants vary but are most often either aesthetic and/or functional in nature.

Aesthetic Reasons for Breast Implant Removal

  • Dissatisfaction with results – Sometimes patients simply do not like the appearance of their breasts after Breast Augmentation.
  • Body Changes – Variations in body weight, natural ageing, and the negative impact of heavier implants on skin quality over time can affect the appearance of the breasts.
  • Lifestyle Changes – Some patients simply outgrow the desire to have larger breasts and want to return to their natural size.

Functional Reasons for Breast Implant Removal

  • Pain and discomfort – Heavier breasts can significantly affect the quality of life and cause pain, especially in the back and neck area.
  • Breastfeeding Concerns – Breast implants can have a negative impact on the ability to breastfeed.
  • Implant Issues – Rupture, Capsular Contracture, and Implant Shifting are some of the complications that are very rare, but still possible.

How Do I Qualify for the Medicare Rebate?

In order to qualify for a rebate from Medicare, you must meet certain Medicare criteria.

The Medicare Benefits Schedule (MBS) uses a numbered list of services subsidized by the Australian Government. Breast implant removal procedures fall into the third category of procedures – therapeutic procedures, and a subgroup of plastic and reconstructive surgery.

MBS Codes for implant removal surgery are:

  • 45554 – Breast Prosthesis Removal and Replacement with the formation of the new pocket
  • 45551 – Breast Prosthesis Removed with Capsule Excision
  • 45548 – Breast Prosthesis Removal

Full MBS Item Number breakdown and description:

45554

Breast prosthesis, removal, and replacement with another prosthesis, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture), including excision of at least half of the fibrous capsule or formation of a new pocket, or both, if:

  • Either:
    • it is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity; or
    • the original implant was inserted in the context of breast cancer or developmental abnormality; and
  • the excised specimen is sent for histopathology and the volume removed is documented in the histopathology report; and
  • photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

45551

Breast prosthesis, removal of, with excision of at least half of the fibrous capsule, not with the insertion of any prosthesis. The excised specimen must be sent for histopathology and the volume removed must be documented in the histopathology report

45548

BREAST PROSTHESIS, removal of, as an independent procedure

For more information, download our Medicare and Health Insurance Guide!

A Guide to Medicare and Health Insurance

Medicare and Health Insurance Guide
 

Will Medicare Cover Breast Implant removal for medical reasons?

In general, Medicare and PHI do not cover procedures performed for aesthetic reasons. This group includes most plastic and cosmetic surgery procedures.

However, if a procedure has the goal of removing or easing a problem that negatively affects your quality of life and daily functioning, you have a good chance that Medicare will cover the costs of that particular procedure. Such a procedure has to be deemed medically justified, necessary, and meet the strict Medicare criteria.

The criteria are:

  • The procedure is not undertaken to enlarge breast size. If replacement of the implant is necessary, it should be the same size as the previous one.
  • If the implant is not implanted due to breast cancer or developmental abnormality, intra-operative photographs must prove that unacceptable deformity is present.
  • The inadmissible deformity does not include asymmetry resulting from the removal of one of the two implants.
  • The rupture, migration of prosthetic material, or symptomatic capsular contracture must be determined by diagnostic imaging.

Thus, in patients in whom there has been an implant rupture, migration of prosthetic material, or capsular contracture, and the procedure was performed for aesthetic reasons, rebates are possible only when the above conditions are met. In other cases, Medicare and PHI do not provide cost coverage.

posting-cosmetic-surgery-photos-videos-online-research-cosmetic-surgery

Research to find out if Medicare and the MBS Covers Your Breast Implant Removal Surgery Procedure

  • The MBS Medical Benefits Scheme has a very comprehensive list of coverage. Which can be downloaded in entirety.
  • Alternatively, you can just use the search function to find your desired procedure.
  • If there is NOT a valid Medicare code for your surgery, your health fund will not cover the procedure.
  • If you would like to view the MBS schedule listing of Medicare rebates, you can visit MBS online.

Thinking about getting a Breast Implant Removal? Download the Breast Implant Removal guide!

Considering Revision Breast Surgery? Get the guide!

Learn more about removing your breast implants.

Breast Revision Download

Our complete guide for breast implant removal surgery contains all the necessary information about the procedure, preparation, and recovery process!

In this guide, you will find out all the answers to frequently asked questions, how to plan breast implant removal surgery and find out if you are a good candidate for this procedure.

Why is Medicare for Breast Implant Removal confusing? There are many reasons why the whole process of applying for rebates for breast implant removal surgery can be confusing. Each surgical procedure is individual and depends heavily on the needs of the patient. And, the reasons for undergoing the procedure can be various. People can opt for such procedures for aesthetic as well as functional reasons in order to improve a certain segment of their life.

In the case where patients decide to have breast implant surgery for aesthetic reasons, Medicare and PHI are very clear. Such interventions will generally not receive approval for a rebate. However, if there are described complications that can cause a certain degree of deformity in the patient, and which meet all the above rules, Medicare and PHI will, after processing the case and a possible positive conclusion, cover the cost of the procedure to a certain percentage.

Life-Changing Effects of Breast Implant Removal Surgery

As previously mentioned, there is a multitude of reasons for Breast Implant Removal Surgery, sometimes patients simply experience dissatisfaction with the result of their breast augmentation and want to return to their natural appearance.

Implants can represent a functional load and limit certain activities such as playing sports and breastfeeding. Furthermore, they can also cause pain and discomfort in the neck and back area. For such patients, breast implant removal surgery can provide not only a sense of satisfaction and increased self-confidence but also a reduction in discomfort and pain.

Thanks to advances in plastic surgery and technological advances in implant development, complications are very rare but still possible. Implant rupture, change of position, capsular contracture, and other complications can also be a health risk that requires surgery. In these cases, the procedure is not optional but mandatory and can prevent negative effects on a patience health, body, and ultimately appearance.

Coco Ruby Blog - Reasons for Breast Implant Removal Before and After Image Comparison

To view more before and after images, you can visit the Breast Implant Removal photo gallery here.

Medicare Rebates are subject to change and review

MBS Item codes can change or be taken off the Medicare rebate schedule, without warning. If your surgery is currently eligible for a Medicare rebate, it may be best to have your procedure sooner rather than later.

Other Plastic Surgeries that can have Medicare and Private Health Insurance cover:

  • Reduction Mammaplasty (with nipple repositioning)
  • Breast Prosthesis Removal
  • Reduction Mammaplasty (without nipple repositioning)
  • Mammaplasty, Augmentation (One Breast)
  • Breast Reconstruction Following Mastectomy (One Breast)
  • Mastopexy (Breast Ptosis) Bilateral
  • Breast Prosthesis Removal & Replacement with the formation of a new pocket
  • Breast Prosthesis Removed with Capsule Excision

These procedures, if aesthetic in nature, cannot be covered by Medicare and PHI. To be eligible to claim a Medicare item you need to visit your GP for a referral before surgery.

Top Tips for dealing with Medicare regarding your claim

  • You should understand the difference between plastic and cosmetic surgery. Plastic surgery can be subject to rebates, while cosmetic surgery due to its nature cannot.
  • Plastic surgery, if reconstructive or necessary, is known as Plastic Reconstructive Surgery
  • Rebates rarely cover the full amount of surgery.
  • Medicare will in no way cover aesthetic procedures if they are not reconstructive and/or functional.
  • Medicare and private health insurance do not have the same extent of services.
  • When talking to Medicare, be specific.
  • Medicare rebates change almost constantly. Try to be as up-to-date as possible.
  • Photographs and medical diagnostic documentation are of paramount importance when applying for Medicare rebates.
  • Use MBS numbers. Read the detailed description of each code and make sure you understand what it is about.
  • Learn what the terms “medically indicated” and “Statement of benefit” refers to.

Further Tips For Claiming Your Breast Implant Removal

  • During your consultation or examination with your doctor or plastic surgeon, ask for a written confirmation that you are seeking the procedure for medical, not aesthetic reasons. Moreover, it is important that your doctor is a professional plastic surgeon, not a cosmetic surgeon operating within the office.
  • General Practitioner referrals are valid for 12 months, while a specialist referral is valid for only 3 months. Our recommendation is that you complete the entire process as soon as possible so that the referral does not expire.
  • Also, it is important that you only have one procedure. Combining procedures usually results in the rejection of the request.

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When phoning Medicare and Health funds

  • The whole process can be quite time consuming and tedious. Prepare for a lot of questions and some stress.
  • Be persistent, but not boring. Avoid too many calls.
  • Write down and keep track of who you are talking to, when you talked and what you talked about.
  • In addition to the phone, use email for inquiries.
  • Ask for written confirmation of all conversations you have.
  • The procedure involves a lot of documents. Don’t lose them and always make copies.

Unfortunately, CocoRuby doesn’t provide assistance with Medicare or Health Fund processing. This is solely the patient’s responsibility. However, we do list the Medicare code(s) on your quote and on your Invoice(s). So, if you are eligible for a Medicare rebate code or health fund rebate, this can help you when it comes to submitting your paperwork.

More Information about Your Procedure

  • You can Download  Free Procedure Guides on your chosen surgery.
  • Our FAQs page might help you find out more about the procedure you are interested in, as well as other patients’ experience.
  • For more information about pricing and payment methods, please visit our page on Surgery Payment options.
  • You can also talk to our Patient Care Team from 8 am – 6 pm Monday to Friday on 1300 264 811
  • Phone 1300 264 811 or send us an enquiry form, below.
Last updated: 14/01/2021
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Michelle Staughton
Michelle Staughton - Patient Liaison Manager at Coco Ruby Plastic Surgery in Melbourne, Victoria, Australia