Will Medicare cover my Breast Implant Surgery?

Medicare Breast implant

Will Medicare cover my Breast Implant Surgery? Removing, Revising, Replacing Your Implants

  • Have you had a boob job and now need breast revision surgery?
  • Did you develop a complication and now need your implants removed?
  • Do you just want your old implants removed and replaced with new ones?

Are you wondering if you can claim any of your Breast Implant Surgery costs through Medicare and your Private health fund? Unfortunately, the answer is not a simple one. Many patients want to know if Medicare will pay for Implant Removal Surgery. It depends on whether or not you meet strict criteria and the circumstances that surround your need for Breast Surgery.

At Coco Ruby Plastic Surgery, we have collated helpful information to make it easier for you and have also added some useful tips and tricks when it comes to dealing with Medicare and Health funds.

If you are looking at whether or not a Breast Lift Surgery can be covered by Medicare we have a separate article “Will Medicare cover my Breast Lift”. This page specifically covers medicare related breast implant surgeries.

implant stack

Breast Surgery MBS Item Numbers

Below are the different MBS item numbers and brief descriptions, you can follow the link or search the numbers to read the full description on the MBS website.

  • 45548 – Breast Prosthesis, removal of, as an independent procedure
  • 45551 – Breast prosthesis, removal of, with excision of at least half of the fibrous capsule, not with insertion of any prosthesis. The excised specimen must be sent for histopathology and the volume removed must be documented in the histopathology report
  • 45553 – Remove and replace Breast implant, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture)
  • 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.

 

Removal and Replacement of Breast Implants Medicare Item Number 45553 and 45554

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If the original procedure was for a cosmetic reason then any issues thereafter are deemed cosmetic treatment complications. Medicare and Private health funds no longer provide rebates for removal and replacement of implants due to medical complications if the original reason for surgery was purely cosmetic.    In exceptionally specific circumstances a Medicare and Private Health Insurance rebate could apply if:

(i) it is demonstrated by intra-operative photographs that removal alone would cause unacceptable deformity; OR
(ii) The original implant was inserted due to developmental abnormality or breast cancer

If your Surgeon and Medicare deem you meet the criteria and your private health insurance policy does allocate you an MBS item number your fund and Medicare will pay a rebate for your anaesthetist’s fees. Your fund may also cover your hospital fees, although this is minus any excess or exclusions.

Tips and Hints when claiming Breast Implant Surgery with Medicare

  • Understand the difference between Plastic Surgery(with medical benefits) versus Cosmetic Surgery.
  • Keep your language precise/accurate
  • Even if you are eligible for a Medicare rebate or health fund coverage, you will still have surgery expenses.
  • Medicare does NOT cover cosmetic procedures.
  • Typically, Medicare will only cover plastic surgery procedures that relate to function or reconstruction.
  • If there is a medical need for your breast implant surgery or it is reconstructive surgery, it’s usually Plastic Reconstructive Surgery (it may have a Medicare code)
  • Rebates are subject to change.
  • Photos taken during your medical consult are critical evidence when it comes to getting eligible Medicare rebates approved.
  • Always give item numbers relating to the entire surgery.
    • You cannot combine separate procedures.
    • It’s important that you read and have comprehensive knowledge of the codes and criteria relating to your surgery
  • If Medicare will not cover your surgery your Private Health fund wont either.
  • If your procedure does have an MBS code, its important that you check any health conditions or other eligibility requirements

General tips when claiming your breast implant surgery on Medicare

  • Ask your surgeon or doctor for written confirmation that your procedure is for medical and not cosmetic reaons.
  • Most procedures that are eligible for rebates require your surgeon to be a GENUINE PLASTIC & RECONSTRUCTIVE SURGEON.
  • In other words not a cosmetic surgeon that operates out of a back room
  • Your surgeon needs to be a Genuine Plastic and reconstructive surgeon.
  • If they are genuine they will have hospital operating rights.
  • As previously stated combining your surgery with other surgeries can alter or even completely VOID any eligibility for cover
  • You will also 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.

Tips for phoning Medicare and Health funds about your Surgery

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  • The process of dealing with Medicare and PHI will not be quick. It will be time-consuming.
  • Save and write down ALL your questions for one phone call or visit.
  • Call twice. Once to get answers to your questions and collect information and a second time to ensure what you got told the first time was accurate.
  • Keep all your information in one place, like a folder or book
    • Write down dates, times and people you speak to (including their name and ID number). If possible also get their direct line and email address.
    • However, if that is not possible, get a reference number and take extensive notes of your phone call/s
  • Know the name of your particular surgery as well as your Surgeons details. In other words, ensure that they are a Specialist with hospital operating privileges
  • Make copies of your forms. ALL of them.
    • We also suggest you take photos of your receipts on your phone.
    • It is better to have backups and not need them than to need them and not have them.

Unfortunately, the staff at Coco Ruby are not able to assist you with your Medicare and Health Fund processing. This is because every patient is different and therefore will have different health funds, physical health and circumstances ETC. At Coco Ruby, we are dedicated to the surgery experience and patient outcomes and this is where our focus needs to stay.

However, we do list the Medicare code(s) on your Quote and on your Invoice(s). So, if you are eligibility for a Medicare rebate code or health fund rebate, this can help you when it comes time to submit your paperwork.

More Information About Your Procedure

  • Download a Free Procedure Guides on your chosen surgery
  • For more information about pricing and payment methods, please visit our page on Surgery Payment options.
  • Visit the FAQs page and patient reviews
  • Alternatively, you can also talk to our Patient Care Team between 8 am – 6 pm Monday to Friday on 1300 264 811 or send us an enquiry form, below.
*Disclaimer: Individual results can vary significantly from patient to patient. The information we provide is general.  For further information on what to expect for your preferred procedures, arrange to see one of our Specialist Plastic Surgeons for a full-history and surgical consultation. Read further information about surgical outcome variability on our Disclaimer page.

 

Last updated: 07/11/2020
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Michelle Staughton
Michelle Staughton - Patient Liaison Manager at Coco Ruby Plastic Surgery in Melbourne, Victoria, Australia