How to get Medicare and Insurance to pay for Gynecomastia or Male Breast Reduction Surgery
Can you get Medicare cover for Gynecomastia Surgery?
Many patients wishing to undergo Gynecomastia or male breast reduction surgery can get Australian Medicare cover for Gynaecomastia Surgery by using item number 31525. However, the surgery must be regarded as medically necessary by Medicare. If you are getting the surgery for purely cosmetic reasons only, Medicare will not pay for it. There must be an underlying medical condition involved.
PLEASE NOTE – Dr Turner does not offer FREE Gynecomastia 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 SIGNIFICANT GAP PAYMENT for your surgery that you have to pay for.
FREE 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.
What are the Criteria for Getting Medicare for Gynecomastia Surgery?
There are several health concerns that can help qualify you for and make it medically necessary such as:
- If your man boobs are causing moderate to severe chest pain, leading to physical/ functional impairment
- Persistent gynaecomastia after cessation of prescribed medications and appropriate screening(s) of non-prescription and/or recreational drugs or substances that have a known side effect of gynaecomastia
- Your breast enlargement condition has been affecting you for more than 2 years and impacts the evaluation of medical causes with supporting laboratory testing has been normal
- Your Glandular breast tissue is the primary cause of gynaecomastia and is documented on physical exam and/or mammography
- To remedy other health conditions that affect your quality of life
Quick Facts about Medicare Cover for Gynaecomastia Surgery
- Medicare only covers breast reduction surgery if it is deemed as medically necessary
- Medicare will not cover cosmetic Gynaecomastia procedures.
- Patients can get coverage under a Medicare plan if you have a valid medical referral and meet strict criteria.
What is Gynaecomastia Surgery?
Gynaecomastia/ Enlarged breasts is a major aesthetic and psychological problem for many men. Gynaecomastia Surgery or Male Breast Reduction is a surgical procedure that is designed to reduce breast size in men. It can be performed for both medical and aesthetic reasons.
Why Should I Consider Gynaecomastia Surgery?
Gynaecomastia surgery can be a life-changing procedure for men struggling with enlarged breast size. It can completely change the way you look and feel about yourself. Some of the reasons to consider breast reduction are:
- Gynaecomastia Surgery can prevent a list of recurring problems that come with having larger breasts and improve your quality of life.
- It will relieve extreme discomfort such as skin chafing & rubbing, redness, and irritation that come as a side effect to having man boobs.
- You will truly see an increase in your self-confidence with your new body. No more shying away in fitted outfits and a bathing suit.
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 or Specialist. You can get it prior to booking an initial consultation with a plastic cosmetic surgeon or after the first appointment.
It is important to demonstrate medical necessity, including any pains, and skin problems. While consulting with your GP, it is worth discussing your symptoms to ensure the clinical need is documented in your referral.
So, will My Gynaecomastia be covered by Medicare?
The answer to this is ‘MAYBE’ – Medicare offers rebates on Gynaecomastia procedures if you meet the special criteria and conditions as listed below.
Will Medicare Cover Breast Reduction Surgery for Medical Reasons? – MBS Codes
If you are diagnosed with gynecomastia and are undergoing a male breast reduction surgery to remove the enlarged tissue for Medical Reasons, you should receive some Medicare benefit.
- BREAST, mastectomy for gyanecomastia, with or without liposuction (suction-assisted lipolysis), not being a service associated with a service to which item 45585 applies (H).
It is important to note that liposuction surgery alone will not be covered by Medicare.
Eligible patients who have private health cover for plastic surgery might be entitled to a rebate on the surgery and may get their hospital fees covered.
If you have required documentation for Male Breast Reduction surgery and you meet the Medical Criteria, you can qualify for a rebate. Please note that recent MBS changes require additional photographic proof, examination evidence, strict patient criteria for rebate and reporting documentation.
People who meet the conditions associated with these item numbers qualify for Medicare rebate in Australia: 31525.
How Do I Qualify for Medicare Gynecomastia Surgery Coverage?
If you are having Gynaecomastia surgery for medical reasons, you will be required to meet multiple conditions. Your doctor needs to verify that:
- Surgery is required to treat certain medical conditions such as persistent pain, skin infections etc.
- Other non-surgical treatment options haven’t worked for you in the past
- You are experiencing medical issues due to man boobs for 2 years or more
Will Health Insurance Help Cover the Cost of Gynaecomastia Surgery?
In order for Insurance or Medicare to help pay for the cost of your surgery, you have to meet strict criteria. It is very important to be aware of the Medicare codes and rebate eligibility criteria as your claim will be completely dependent on these factors.
If you qualify for Medicare, chances are that you will also be eligible for a rebate on the Gyno Surgery from your Private Health Insurance Provider if you have the right level of cover and are outside the waiting period. This only applies if you meet the criteria for Medicare Item Number 31525.
It is important to check directly with your Private Health Fund to find out about your policy as they can differ from fund to fund.
Why is the Medicare Rebate for Gynecomastia Surgery Confusing?
The confusion can be attributed to variables of the situation. Each patient is different and has different reasons for getting Male Breast Reduction Surgery done. In certain cases, . Please note that rebates are only available for reconstructive plastic surgery procedures which are deemed as essential for the health of the patient.
The guideline for Medicare rebates is very clear. Medicare will not pay for ‘non-therapeutic cosmetic surgery’ and ‘non-therapeutic plastic surgery’ procedures. Significant neck and back pain and skin infections related to man boobs 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 Gyno surgery, it is best to get the procedure sooner rather than later.
Will My Private Health Fund Cover My Gynecomastia Procedure?
Private Health Funds only cover a procedure if;
- You meet the Medicare eligibility criteria and have an MBS item number
- Patients have 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 Gynaecomastia Surgery Cost If Self-Funded?
The cost of having a Gynecomastia Surgery performed by a Specialist Plastic Surgeon in Australia varies significantly based on the area, expertise, and experience of the surgeon. This is because Gynaecomastia Surgery is customised to fit your unique needs and achieve the desired results.
You can contact Dr Turner’s team on 1300 437758 for an estimated cost or come in for a consultation to determine the exact quote. Our team will enable you to understand the costs/risks associated with the surgery. We will 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 Gynaecomastia 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.
Funding Your Gyno Surgery
Can I Use My Super Fund to Pay for Gynaecomastia Surgery?
There are some patients who wish to use their own super fund to pay for their Gynaecomastia surgery. Prior to requesting the early release of funds, it is 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
Can I have a Gyno Surgery Payment Plan?
Medical Finance companies may be able to help you fund your surgery. Please visit the Finance and payment plan page for more information. You can also prepay your surgery over time as a pre-payment plan.
Medicare for Gynecomastia FAQs
Here is are the answers to frequently asked questions we get regarding Medicare rebate for Gynaecomastia surgery:
Can gynecomastia be covered by Medicare?
- Maybe, Gynaecomastia is covered by Medicare if it is deemed as a medical necessity. Medicare will not pay for the surgery if you are getting it done due to cosmetic reasons only. The MBS item number for Gynaecomastia surgery is 31525.
Can I claim insurance for gyno surgery?
- If you meet the criteria for a Gyno Medicare rebate, you may be eligible for insurance for Gynaecomastia surgery. However, it is important to check in directly with your service provider as the policies vary from fund to fund and you willo need the right level of cover
Does Medicare cover gyno surgery for men?
- Yes, Medicare covers gynaecomastia surgery for men if it is deemed medically necessary and you meet the criteria of MBS Item Number 31525.
How much is men’s breast reduction?
- The price of make breast reduction varies significantly based on the area, experience, and expertise of the surgeon. To determine the exact quote, you can book a consultation with Dr Turner or contact our team for an estimated quote.
How do I claim a Medicare for Gyno rebate?
- In order to claim a rebate for Male Breast Reduction Surgery, a GP must refer you to a specialist surgeon. The surgeon will determine whether your procedure is cosmetic/ reconstructive in nature. If it is medically necessary, then this is what will happen next. You will get the surgery done. You will pay the bill and submit it as a claim to receive a rebate.
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.