How to get Medicare and Insurance to pay for Breast Reduction Surgery
Can you get Medicare to cover Breast Reduction?
Many patients get coverage for breast reduction through Medicare in Australia using the popular Medicare item number 45523. The procedure must be seen as a medical necessity by your surgeon and Medicare. It essentially means that you are getting the surgery due to an underlying medical condition. If your surgery is due to purely cosmetic reasons only, Medicare won’t pay for it.
PLEASE NOTE – Dr Turner does not offer FREE Breast Reduction surgery. Medicare and/or your Private Health Insurer may offer a PARTIAL SUBSIDY for a procedure to be done in a private plastic surgery practice like Dr Turner’s. There will still be a GAP PAYMENT for your surgery that you have to pay for.
Plastic surgery MAY be available in some public hospitals for some procedures but there is a significant waiting period – sometimes many years spent waiting for elective surgery. If you want your surgery sooner than that and can’t afford it – please consider other funding options.
Dr Scott Turner is a Specialist Plastic Surgeon and Specialises in Breast Reduction Surgery – find out more about his Breast Reduction Surgery and look at his Breast Reduction before and after results.
What are the criteria for getting Breast Reduction Medicare?
There are several health concerns that can help qualify you for Breast Reduction Surgery and make it medically necessary including:
- Chronic skin infections due to larger breasts. The common one is intertrigo.
- Relief from body pain; back pain, neck pain or shoulder pain
- To remedy other health conditions that affect your quality of life
Quick Facts about Medicare Cover for Breast Reduction
- Medicare only covers breast reduction surgery if it is medically necessary.
- Medicare does not cover elective cosmetic breast reduction.
- Patients can get coverage under Medicare plan if it is deemed as a medical necessity, you have a valid referral and meet strict criteria.
Read our blog Will Medicare Cover My Surgery?
What is Breast Reduction Surgery?
Breast reduction is a surgical procedure that reduces the size of your breasts by removing excess fat, tissue, and skin. It is an ideal procedure for anyone who has large breasts that look out of proportion to the rest of their body. Heavy breasts can lead to skin infections, neck, back and shoulder pain.
Why Should I Consider A Breast Reduction?
Breast reduction is truly a life-altering procedure. The surgery can prevent and treat plenty of recurring problems that come as a side effect to having larger breasts and give you a better quality of life.
Most of the patients feel extremely confident and happy post the surgery. It is almost like they have a new outlook on life and are able to dive into a wide range of physical activities. Moreover, the surgery also improves self-confidence and body image.
With the new confidence and body, you will be able to rock all those clothing options that you previously didn’t. Trust me, it is one of the most fun advantages of getting the surgery.
Research shows that woman’s health improves significantly post-reduction mammoplasty. Neck pain, back pain, shoulder pain, infections and rashes will be completely gone after getting the procedure done.
You’ll need a Medical Referral with Documented concerns
In order to claim your surgery on Medicare, you will need a Medical Referral from your General Practitioner. You can get it prior to booking an initial consultation with a cosmetic surgeon or after the first appointment.
It is important to demonstrate medical necessity, including pain in the neck and/or shoulder region. While consulting with your GP, it is worth discussing your symptoms to ensure the clinical need is documented in your referral.
So will my Breast Reduction be covered by Medicare?
The answer to this is ‘MAYBE’ – Medicare offers rebates on breast reduction procedures if you meet the special criteria and conditions as listed below.
How Do You Qualify for Medicare Rebate for Breast Reduction Surgery? – MBS Codes
These MBS Codes may be applicable for Breast Reduction Surgery:
(a) for patients with macromastia and experiencing pain in the neck or shoulder region; and
(b) not with insertion of any prosthesis
45520 Reduction mammaplasty (unilateral) with surgical repositioning of the nipple, in the context of breast cancer or developmental abnormality of the breast
45522 Reduction mammaplasty (unilateral) without surgical repositioning of the nipple:
(a) excluding the treatment of gynecomastia; and
(b) not with insertion of any prosthesis
What these terms mean:
- Macromastia – the condition of having abnormally large breasts. (Breast Hypertrophy)
- Prosthesis – an artificial body part e.g. a breast implant
- Bilateral – both sides / both breasts
- Unilateral – one side / one breast
- Gynecomastia – Excess Male Breast Tissue
Will Medicare Cover Breast Reduction Surgery for medical reasons? – MBS Criteria
If you have required documentation for breast reduction surgery and you meet the Medicare criteria, you can qualify for a rebate. It is important to note that the recent MBS changes included additional photographic proof, examination evidence, reporting documentation, and stricter patient criteria for Medicare rebates.
Your eligibility will essentially be based on the following Medicare criteria;
(a) for patients with macromastia (large breasts) and experiencing pain in the neck or shoulder region; and
(b) not with insertion of any prosthesis – this means you cannot have an implant put in when having the reduction to be able to claim the rebate
What are the Medicare breast reduction criteria in Australia?
How do I qualify for the coverage of Medicare Breast Reduction?
You can qualify for breast reduction coverage if you meet Medicare’s criteria.
If you’re having breast reduction due to excessive pain, you’ll be required to meet multiple conditions. In this case, your doctor needs to verify that:
- Surgery is essential to treat the pain
- Other non-surgical treatments haven’t worked for you in the past
- You are having persistent pain for a minimum of six months
There are certain cases when the pain is caused by a specific breast condition such as breast hypertrophy. Hypertrophy causes your breasts to increase in size which causes pain and a variety of other problems. Medicare will cover the cost of breast reduction if your doctor indicates that pain is caused by hypertrophy.
- 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
- Reduction mammaplasty (unilateral) with surgical repositioning of the nipple, in the context of breast cancer or developmental abnormality of the breast
- Reduction mammaplasty (unilateral) without surgical repositioning of the nipple:
- (a) excluding the treatment of gynecomastia; and
- (b) not with insertion of any prosthesis
Will health insurance help cover the cost of the Breast Reduction surgery?
You need to meet strict criteria for your insurance or Medicare to pay for the surgery. It is important to be fully aware of Medicare codes and rebate eligibility criteria as these two factors will change/affect your claim.
If you qualify for Medicare you may also be eligible for rebates on the Reduction surgery from your Private Health Insurance Provider. This only applies if your condition meets the criteria for Medicare Item Number.
For most breast reduction surgeries, Bronze Hospital cover is enough. In some cases, Silver Hospital cover might be required as well. It is important to check directly with your own Private Health Fund, regarding your policy as they can differ.
Why is the Medicare Rebate for Breast Reduction Confusing?
This is due to the variables of the situation. Each patient is different and has different reasons for getting the surgery done.
In some cases, Medicare offers a minor rebate on certain procedures. It is important to note that rebates are generally available for reconstructive plastic surgery only if the surgery is deemed ‘essential’. For a lot of patients, breast reduction will be under this category.
When it comes to Plastic & Cosmetic Surgery, the Medicare REBATE guidelines are quite clear. Medicare does not cover ‘non-therapeutic cosmetic surgery’ NOR ‘non-therapeutic plastic surgery’ procedures. Significant Breast Ptosis after pregnancy, Chronic Back Pain, and skin infections related to large breasts are chronic medical conditions.
NOTE – Medicare Rebates are subject to change and review
Please note that MBS Item codes are reviewed regularly and can be changed/eliminated from the Medicare rebate schedule at any time. If you are currently eligible for a Medicare rebate for breast reduction surgery, it is best to get the procedure sooner rather than later.
Will my private health fund cover my breast procedure?
Private Health Funds only cover a procedure if;
- The patient meets current Medicare eligibility criteria and has an MBS item number.
- You need to meet the strict criteria for Medicare rebate to quality for health fund cover and provide proof.
- Extensive documentation, examinations, imaging or volumetric testing, and photographs are required to substantiate a claim.
How much will my Breast Reduction cost if self-funded?
The cost of having a Breast Reduction performed by a Specialist Plastic Surgeon in Australia varies depending on the area, experience and expertise of the surgeon, and your unique needs.
It is primarily because the breast reduction procedure is customized to suit the needs of an individual and the desired outcome.
You can contact Dr Turner’s team for an estimate or come for a consultation to get a quote. We will also help you understand the costs and risks associated with the surgery. Our team can also help you access your eligibility for coverage by MBS or your health fund.
In order 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 Dr Turner. You will need a valid referral at the time of surgery. A GP referral lasts for 12 months.
You can also speak to our knowledgeable Patient Care Team, who are available to answer your questions.
Can I Use My Super Fund to pay for Breast Reduction Surgery?
Some patients use their own super fund to pay for their breast reduction surgery. Before requesting the early release of funds, it is very important to note that:
- Each application for early Super release is assessed on an individual basis and financially assessed.
- Superfund withdrawal applications can be made through your MYGOV account via the ATO.
- Tax implications apply. The withdrawal may be taxable. Hence, it is important to seek professional financial advice.
Breast Reduction Medicare FAQs
How can I get a breast reduction with Medicare?
It is possible if your breast reduction surgery is a medical necessity and you meet the strict criteria that Medicare will pay for the procedure. The first step is to visit your GP and get the documentation that supports the ‘necessity’ element of the medicare surgery. Then call Dr Turner.
What qualifies a woman for breast reduction?
You are most likely an ideal candidate for breast reduction if:
- You are physically healthy with no chronic illnesses
- You have realistic expectations from the treatment
- You don’t smoke or can quit it for the specified interval
- You are bothered by feeling that your breasts are too large in comparison with the rest of your body
- You have limited physical activity due to large breasts
- You experience back, neck and shoulder pain that is caused by the excessive weight of your breasts
- You get shoulder indentations from wearing a bra
- You experience skin irritation beneath the breast crease due to rubbing of the skin
- Your large breasts are impacting your day to day life
Do I need a medical referral to get my Breast Reduction Medicare?
- Yes, you need a medical referral to get Medicare for Breast Reduction. You can get a referral from a GP or Medical Specialist.
Can I have a breast reduction done in the public system?
- There is a limited NSW public training hospital budget for breast reductions and due to covid – a very long waiting list for elective surgery. You will be unlikely to have a highly experienced and skilled plastic surgeon perform a public breast reduction surgery. Please call the NSW Government Surgery Access Line on 1800 053 456 for more info.
Does Bupa cover breast reduction surgery?
- BUPA may cover your breast reduction if you qualify for the Medicare Item Number and have the right level of BUPA Insurance cover – please phone BUPA and ask about coverage for Item Number 45523 (Both breasts)
Always Do Your Research
- Enquire to find out more about your surgery
- Please read our website to learn more about your intended procedure
Do you need a Medical Referral to see Dr Turner?
- A GP Referral is required to Consult with Dr Turner (under new AHPRA Regulations)
- Please obtain a referral from your GP or Specialist if you want a consultation for an MBS item number surgery.
- Please note that your Medicare Rebates will NOT be claimable without a valid recent Medical Referral
Making The Most Of Your Consultation
- Please arrive slightly early for your in-person consultation
- You are welcome to bring a friend or relative to help consider the information and discuss your options
- Please be aware you may need to undress for a physical exam so wear simple clothes
- Ensure you also take a lot of notes during the consultation and thoroughly examine all the documents provided
Want more information before scheduling your consultation?
- Find out more about pricing and payment plans
- Request more information about the procedure – call or contact us
How to Book Your Consultation
- You can book your initial consultation by paying the $350 cosmetic consultation fee in advance – when you make your appointment
BOOK A PHONE CALL FOR MORE INFO
- To find out more information about surgery you can book a FREE 15-minute phone conversation with our Friendly Patient Care team via Calendly- Book Consultant 1 or Book Consultant 2
Contact us or call on 1300 437 758 to arrange your surgeon consultation in Sydney.