A Guide to Medicare Cover for Breast Lift and Health Insurance
Can I claim my Breast Lift on Medicare?
Patients often ask if they can claim their Breast lift on medicare. Sagging or droopy breasts can cause infections and rashes. Breast lift surgery, also known as Mastopexy surgery can help reduce these effects.
Unfortunately, there is not a simple yes or no answer, however, there is a possibility. Medicare MIGHT offer rebates on Mastopexy surgery and breast reduction procedures. But you need to meet special criteria and conditions (which will be explained below).
Will your private health insurance cover you and contribute to the costs?
In order to claim your Breast Lift surgery using your private insurance, you must be eligible for the Medicare item number. Furthermore, you also need to deal with your health fund directly regarding funding contributions to determine if you are eligible with the level of cover you have.
Some Super Funds also allow early release of funds to use for boob lift surgery, under strict criteria.
Popular Reasons for wanting to have Breast Lift Surgery
- As previously stated, rashes and chronic skin infections
- Significant sagging or breast ptosis. When at least two-thirds of breast tissue is below the inframammary fold. Also known as the crease under the breast.
- As well as, other breast-weight related health conditions that impact not only on your health but also your quality of life
How Do I Qualify for the Medicare Rebate?
In order to qualify for a rebate from Medicare, you must meet certain Medicare criteria.
Your eligibility to claim your breast lift with Medicare will depend on the degree of breast ptosis (breast sagging) as well the age of your youngest child.
The below MBS Codes may be applicable for Breast Lift Surgery
- 45558 Breast Lift Mastopexy – Bilateral (both breasts)
- 45556 Breast Lift Mastopexy – Unilateral (one breast only)- payable only once per occasion
Full MBS Item Number breakdown/Description
- 45558 Breast ptosis, correction by mastopexy of (bilateral), if: (a) at least two-thirds of the breast tissue, including the nipple, lies inferior to the infra-mammary fold where the nipple is located at the most dependent, inferior part of the breast contour; and (b) if the patient has been pregnant-the correction is performed not less than 1 year, or more than 7 years, after completion of the most recent pregnancy of the patient; and (c) photographic evidence (including anterior, left lateral and right lateral views), with a marker at the level of the inframammary fold, demonstrating the clinical need for this service, is documented in the patient notes Applicable only once per lifetime (Anaes.) (Assist.)
- 45556 Breast ptosis, correction of (unilateral), in the context of breast cancer or developmental abnormality, if photographic evidence (including anterior, left lateral and right lateral views) and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes – Applicable only once per occasion on which the service is provided
Will Medicare Cover Breast Lift Surgery for medical reasons? – If you meet the MBS Criteria
Breast surgery may be necessary for medical reasons and to potentially improve your well-being.
To be eligible to claim for a Medicare rebate for your breast lift surgery it will need to be deemed medically necessary, this is achieved by meeting the following strict Medicare criteria. Not all patients will meet the following criteria:
- Your GP or plastic surgeon will need to assess the degree of breast sagging (breast ptosis and nipple location). Moreover, the nipple has to be significantly beneath the inframammary fold and photographic evidence is required
- Furthermore, IF you have been pregnant – your youngest child needs to be between the ages of 1 and 7 years old at the time of your surgery. However, if you have not been pregnant these criteria does NOT apply.
- You will also need to get and hold a current medical referral at the time of surgery. A GP Referral lasts 12 months whilst a referral from a specialist only lasts 3 months.
Find out about the medicare criteria for breast reduction surgery on our blog page.
Research to find out if Medicare and the MBS Covers Your Surgery Procedure
- The MBS Medical Benefits Scheme has a very comprehensive list of coverage. Which can be downloaded in its 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 Breast Lift Surgery? Download the Breast Lift Surgery guide!
Why is Medicare for Breast Surgery confusing a lot of patients seeking Plastic or Cosmetic Surgery?
This is due to the fact that there are so many variables. So much depends on the individual and the procedure required. Medicare will sometimes offer a very minor rebate on some procedures.
Generally, rebates are only available for reconstructive breast lift procedures or what is considered ‘essential’ surgery. Unfortunately, not all breast surgeries will fall under this category. A breast lift and breast reduction may be considered for some patients. However, Breast Augmentation is rarely covered – maybe if a congenital defect like asymmetry or tuberous breasts.
When it comes to cosmetic and plastic surgery, the Medicare rebate guidelines are very clear.
Medicare won’t cover non-therapeutic cosmetic surgery and non-therapeutic plastic surgery procedures.
Life-Changing Effects of Breast List Surgery
There are multiple benefits to getting a breast lift and most patients will enjoy many lifestyle benefits post-surgery. In addition to feeling more confident, having better health and looking better in clothes many patients also find that lessening the sag of the breasts leads to improved posture.
Furthermore, the reduction of sagging breast tissue makes keeping fit much easier thus further improving not only your appearance and mental health but overall physical health as well.
To view more before and after images you can visit the Breast lift Before and After Photo Gallery
Medicare Rebates are subject to change and review.
MBS Item codes can change or be eliminated from the Medicare rebate schedule. If your breast lift surgery is currently eligible for a Medicare rebate, it may be best to perform your procedure sooner rather than later.
Other Plastic Surgery that can have Medicare and Private Health Insurance cover:
Other plastic surgery procedures that Medicare might cover (depending on eligibility) include;
- Breast Asymmetry
- An eyelid lift, also known as Blepharoplasty.
- Breast lift or breast reduction surgery (specific criteria apply)
- Breast reconstruction surgery following a mastectomy
- Similarly, Breast prosthesis following a mastectomy
- Facial or nose reconstructive plastic surgery (when for accident or trauma)
- Septoplasty or Rhinoplasty. In other words, corrective nose surgery (if breathing is impaired by nose injury).
- As well as a deviated septum and other types of nasal structural abnormality
- Body lift surgery, which involves ‘tightening’ of excess skin after rapid weight loss
- As well as, Bariatric weight loss surgery for obesity
Currently, Medicare only covers medical and surgical procedures that are deemed clinically necessary for your health. There is no cover for elective plastic surgery or cosmetic procedures for purely cosmetic reasons, such as liposuction or breast enlargement. 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 about your claim
- Know the difference between Medicare and your Health Fund
- Similarly, understand the difference between asking about Plastic Surgery (with medical benefits) versus Cosmetic Surgery (without). Plastic Surgery is sometimes called Cosmetic Plastic Surgery.
- Be aware that even if you are eligible for a Medicare rebate or health fund coverage, you will most likely still have surgery expenses. Rebates rarely match actual plastic surgery costs.
- Medicare WILL NOT cover purely cosmetic procedures – don’t ask! Typically, Medicare only covers plastic surgery procedures that relate to function or reconstruction.
- Keep your language precise/accurate when speaking to medicare and your health fund about your specific surgery.
- Some people mistake the terms of plastic and cosmetic surgery. It is plastic surgery and reconstructive surgery.
- While these terms are interchangeable sometimes when dealing with health funds and or Medicare it is important not to confuse terms.
- If it has a medical need or is reconstructive surgery, it’s usually Plastic Reconstructive Surgery.
- Some MBS rebate codes include more comprehensive procedures than others.
- Read and have an understanding of the codes and criteria in the area relating to your surgery.
Tips for dealing with your Health fund
- If Medicare does not cover your surgery you will also lose any potential health fund rebates too.
- Health Funds will only provide coverage when there is a Medicare Number attached to your procedure.
- If your procedure has an MBS code, its imperative you check any health conditions or other eligibility requirements.
- Your level of cover at your health fund is critical – many surgeries now require GOLD level Cover
- Find out the meaning of “medically indicated” and “Statement of benefit”.
Further tips for claiming your breast lift
- Ask your surgeon or doctor to confirm IN WRITING that your procedure is for medical and not cosmetic reasons. It needs to meet the strict requirements of the Medicare rebate code criteria.
- Procedures that are eligible for rebates often require a GENUINE PLASTIC & RECONSTRUCTIVE SURGEON. NOT simply a doctor or so called cosmetic surgeon that operates out of a back-room
- Make sure your surgeon is a Genuine Plastic and Reconstructive surgeon. And, that they have hospital operating rights.
- Combining your surgery with other surgeries can alter or even completely VOID any eligibility for cover.
- As stated previously you need to have a referral from a GP or Specialist stating your medical conditions.
- GP Referrals are valid for 12 months.
- Whilst a specialist referral only lasts for 3 months.
- HINT: Ensure your referral does not become invalid before the date of your surgery.
When phoning Medicare and Health funds
- Expect the process to be not only time-consuming but energy-consuming as well.
- Save and write down ALL your questions for one phone call or visit. AVOID making lots of short phone calls.
- Collate all your information in one place, in either a folder or a book
- Keep all your questions – and subsequent answers in one place.
- Write down dates, times and people that you speak to (including their name and ID number).
- If possible get the number for their direct line and email address.
- If that’s not possible, at least get a reference number and take extensive notes of your phone call/s
- Call twice. By making two different phone calls and speaking to two different people you can cross-reference the information and ensure you have received the correct information & advice.
- Ask for your advice in writing or by email. Ask for written confirmation of the conversation and data via email
- Know the name of your particular surgery AND the details of your chosen Surgeon. In other words, ensure that they’re a Specialist with hospital operating privileges
- ALWAYS make copies of ALL your forms before you submit them.
- We recommend taking photos of your receipts on your phone as well.
- This is a backup plan, in the event that your information goes missing.
Regrettably, we are not able to aid you with Medicare or Health Fund processing. This is solely the patient’s responsibility.
This is due to the fact that each patient will have different criteria, concerns and health funds etc. We are dedicated to surgery experience and outcomes.
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
- Download a Free Procedure Guides on your chosen surgery
- Visit the FAQs page and patient reviews
- 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