---
title: "Will Medicare Cover Breast Implant Removal? A 2026 MBS Guide"
url: https://drturner.com.au/blogs/will-medicare-cover-my-breast-implant-removal/
date: 2022-03-31
modified: 2026-07-31
author: "Dr Scott J Turner"
description: "Dr Scott J Turner | Specialist Plastic Surgeon (FRACS) Key Takeaways Medicare may contribute to breast implant removal when there is a recognised medical indication that meets a Medicare Benefits..."
categories:
  - "Breast Implants"
tags:
  - "Breast implants removal surgery"
  - "Medicare for breast implant removal surgery"
  - "Medicare for breast implants removal"
  - "Will Medicare cover my breast explant surgery"
  - "Will Medicare cover my surgery"
image: https://drturner.com.au/wp-content/uploads/2024/04/blogplaceholder-img.svg
word_count: 2264
---

# Will Medicare Cover Breast Implant Removal? A 2026 MBS Guide

*[Dr Scott J Turner](https://drturner.com.au/dr-scott-turner-sydney-plastic-surgeon/) | Specialist Plastic Surgeon (FRACS)*

> **Key Takeaways**
>
>
>
>
> - Medicare may contribute to breast implant removal when there is a recognised medical indication that meets a Medicare Benefits Schedule item, such as capsular contracture, rupture or an implant-related complication.
> - Medicare does not cover removal simply because a patient no longer wants implants, wants a different size, or is seeking cosmetic revision only.
> - Four MBS items relate to removal: 45548, 45551, 45553 and 45554. Each has specific, documented criteria that must be met.
> - Even where an item applies, Medicare covers only part of the scheduled surgical fee. Hospital, anaesthetic and other costs mean meaningful out-of-pocket expenses remain.
> - Replacement of cosmetic implants is rarely covered. Items 45553 and 45554 exclude implants originally placed to increase breast size, with narrow exceptions.
> - Breast implant illness symptoms alone are not a listed indication, but a coexisting physical finding such as contracture or rupture may be.
Whether Medicare covers breast implant removal is one of the most common questions patients ask when considering explant. The answer is sometimes yes, but not always. Medicare does not cover removal simply because a patient no longer wants implants; a rebate may apply where there is a recognised medical reason, such as capsular contracture, rupture, an implant-related complication or specific findings that meet the Medicare Benefits Schedule criteria.

This is where many patients become confused. Some arrive expecting a rebate based on what they have read online; others assume they will not qualify, only to find that their imaging or examination findings may support an item number. This guide explains how eligibility works, what the relevant MBS items mean, and what documentation is usually required. The surgical pathway itself is on the [breast implant revision and removal](https://drturner.com.au/procedures/breast-body/breast-implant-revision/) page, the recovery side is in [recovery after breast implant removal](https://drturner.com.au/blogs/recovery-after-breast-implant-removal-procedure/), and the surgical options in the [en-bloc and capsulectomy guide](https://drturner.com.au/blogs/patient-safety-advisory-breast-implant-removal-and-capsulectomy/).

## The core principle: medical necessity

Medicare may provide a rebate for breast implant removal where the procedure is medically necessary. It does not cover purely cosmetic procedures, and changing your mind about implants is not a Medicare-eligible indication.

This is the most important point to understand. The MBS items for breast implant procedures have specific clinical criteria that must be met and documented. A surgeon cannot assign an item number to a patient whose clinical situation does not fit the criteria, and where a clinic suggests it can, that should be regarded cautiously. On cost: even where an item applies, Medicare typically covers around 75 per cent of the MBS scheduled fee for the surgical component only. It does not cover hospital fees, anaesthetist costs, implant costs or most other associated expenses, so meaningful out-of-pocket costs usually remain. Public hospitals may offer some procedures at no cost, but waiting periods can extend to years.

## Current MBS items for breast implant removal

As of 2026, four MBS items relate to breast implant removal, each with specific criteria.

| Item | Covers | Key requirement |
| ---- | ------ | --------------- |
| 45548 | Removal without capsulectomy or replacement | A documented reason for removal; not payable for purely cosmetic surgery |
| 45551 | Removal with excision of at least half the capsule, no replacement | A medical indication such as contracture, capsular mass or malignancy; capsule sent for histopathology with volume documented |
| 45553 | Removal and replacement following specified medical complications | Strict criteria; excludes implants originally placed to increase breast size, with narrow exceptions |
| 45554 | Removal and replacement with capsulectomy or new pocket formation | As for 45553, plus the histopathology requirement |

### Item 45548: removal without replacement

Item 45548 may apply to straightforward removal without capsulectomy and without replacement. Whether it is appropriate depends on the planned procedure, the clinical context and the surgeon's assessment. Medicare does not provide benefits for purely cosmetic surgery, so the reason for removal and its documentation still matter.

### Item 45551: removal with capsulectomy

This covers removal with excision of at least half of the fibrous capsule, without inserting a new implant. Its criteria are often misrepresented in patient-facing content. It is intended to be claimed where there is a medical indication for the capsulectomy, such as capsular contracture, particularly Baker grade III or IV; a mass within the capsule seen on imaging or during surgery; or evidence of BIA-ALCL or other malignancy. Two documentation requirements are specific to this item: the excised specimen must be sent for histopathology, and the volume of capsule removed must be documented in the histopathology report.

### Items 45553 and 45554: removal and replacement

These cover removal and replacement of a breast prosthesis following medical complications, and the criteria are significantly narrower than many patients expect. Item 45553 covers removal and replacement following medical complications such as rupture, migration of prosthetic material, or symptomatic capsular contracture. Item 45554 covers the same with excision of at least half the capsule or formation of a new pocket, or both.

The critical limitation is that benefits are not payable under either item where the procedure is performed solely to increase breast size, and where the original implants were inserted for purely cosmetic reasons the exceptions are narrow. Either it must be demonstrated by intra-operative photographs taken post-removal, with the patient in the supine position, that removal alone would cause an unacceptable deformity, meaning a discrete concavity in the chest contour; or the original implant must have been inserted in the context of breast cancer or a developmental abnormality. Asymmetry from single-implant removal is not considered unacceptable deformity under these criteria. The practical effect is that for most patients who had cosmetic augmentation and want replacement implants after a complication, Medicare and private health insurance generally do not contribute to the replacement cost. Where the original implants were placed following mastectomy or for a developmental abnormality, 45553 or 45554 may apply when complications arise.

## Medical indications that may qualify

The indications most commonly associated with a Medicare-eligible removal:

- **Capsular contracture**, Baker grade III or IV, where visible distortion or pain is present. This is the most common eligible indication, and its grading is covered in the [capsular contracture guide](https://drturner.com.au/blogs/what-is-capsular-contracture-and-how-can-it-be-treated/).
- **Rupture or leakage** confirmed on imaging, with MRI most reliable for silicone gel. Silent rupture picked up on surveillance imaging can qualify.
- **Infection** caused by the implants where conservative management has not resolved it.
- **Implant extrusion**, where the implant becomes exposed through the skin.
- **Interference with breast cancer diagnosis or treatment** where implants must be removed for appropriate oncological management.
- **Siliconoma or granuloma formation** causing palpable masses or symptoms.
- **Implant migration** causing deformity or symptoms.
- **BIA-ALCL**, covered in its own [guide](https://drturner.com.au/blogs/bia-alcl-symptoms-diagnosis-and-treatment-of-breast-implant-associated-lymphoma/).
- **A confirmed mass within the capsule** on imaging or found during surgery.

Which item, if any, applies is assessed at consultation against your specific findings.

## Where breast implant illness fits

Breast implant illness is one of the areas where eligibility is most confusing. Some patients experience symptoms such as fatigue, joint aches, cognitive difficulty, rashes or sleep disturbance and wonder whether removal will be covered. The difficulty is that these symptoms alone are not listed as an indication under the current criteria for capsulectomy.

That does not mean the symptoms are dismissed. It means eligibility usually depends on whether there is also a documented physical finding, such as capsular contracture, rupture, a seroma or a mass. This is why careful assessment, examination and imaging matter: for some patients the primary concern is breast implant illness, but the Medicare pathway, if one applies, rests on a documented physical finding. Patients who initially expect their symptoms to be the basis of a claim are sometimes advised after workup that a physical finding such as a confirmed contracture is the actual basis of eligibility. The clinical position on those symptoms is covered in the [breast implant illness guide](https://drturner.com.au/blogs/latest-update-on-breast-implant-illness-symptoms-and-treatment/).

## The pathway to a Medicare claim

**GP referral.** Start with a GP appointment to discuss your symptoms and concerns. A valid GP referral is required for Medicare eligibility, and GP referrals are generally valid for 12 months, while a specialist's referral is valid for three. The GP consultation may include an initial examination, documentation of symptoms, and any initial blood work or imaging.

**Specialist consultation.** At the initial consultation your history is assessed, the breasts examined, any imaging reviewed, and whether your situation meets MBS criteria is discussed. If an item applies, it and its criteria are explained; if not, the honest answer is given at that stage rather than after surgery. The consultation also covers surgical options, risks, realistic expectations and the costs involved, including what Medicare and private health insurance may and may not contribute. Bring previous implant records, imaging reports, Medicare details and your GP referral.

**Imaging and documentation.** Depending on symptoms and findings, investigations may be needed to confirm medical necessity and support the claim: ultrasound for capsular issues, seromas or extracapsular silicone; MRI, the most reliable test for silent silicone rupture; photographic documentation of appearance and any distortion; and clinical examination findings documenting contracture grade or masses. Comprehensive documentation is central to a claim being accepted, including a detailed surgeon's report of the specific indication, imaging reports, photographic evidence where relevant, and documentation of any failed conservative management.

**Surgery and claim.** After surgery the clinic team assists with claim submission. For a 45551 claim, the histopathology report confirming capsule excision volume is an essential part of the claim.

## Private health insurance and out-of-pocket costs

If your procedure qualifies for an item number, your private health insurance may provide additional benefits. Where no item applies, private health insurance generally will not contribute either, because it follows the Medicare pathway. Where it does apply, it typically covers hospital accommodation and theatre fees, contributions toward anaesthetist fees, and part of the gap depending on policy.

The level of cover depends on the specific policy. Most patients need appropriate hospital cover, typically silver or gold tier, for plastic surgery item numbers, and bronze tier policies often exclude the relevant categories entirely. Always check directly with your fund, citing the specific item number, to confirm your cover. The total cost of removal is made up of the surgeon's fee, the anaesthetist's fee, the hospital facility fee, and the cost of any additional procedure such as a lift performed at the same time. Even with a Medicare rebate and private cover, expect meaningful out-of-pocket expense, and a detailed quote is provided after consultation. For patients whose situation does not meet MBS criteria, the full cost is self-funded.

## The cosmetic pathway, where Medicare does not apply

Where explant is purely cosmetic, with no medical indication meeting MBS criteria, the cosmetic surgery framework introduced on 1 July 2023 applies: a GP referral before the first surgical consultation, two consultations with the surgeon, a psychological evaluation where indicated, and a seven-day cooling-off period. Medicare does not contribute, and the full cost is self-funded. Those cosmetic-pathway requirements do not apply when the explant is medically indicated and meets MBS criteria, in which case the standard surgical consultation pathway applies. The same operation therefore follows different consultation and consent frameworks depending on whether the indication is medical or cosmetic, and which applies to your case is explained at consultation.

## Frequently asked questions

**Does Medicare cover breast implant removal for breast implant illness?**

Breast implant illness symptoms alone, without a coexisting physical finding, are not listed in the current MBS criteria for removal with capsulectomy under item 45551. Many patients who attribute symptoms to breast implant illness also have physical findings such as capsular contracture or confirmed rupture that do meet the criteria, in which case Medicare may apply. A thorough workup before surgery clarifies which items, if any, are relevant.

**Does Medicare cover breast implant replacement?**

For patients whose original implants were inserted for purely cosmetic reasons, Medicare typically does not cover replacement even when a complication arises. Items 45553 and 45554 require either that the original implant was for cancer or a developmental abnormality, or that intra-operative photographs taken with the patient supine demonstrate a specific unacceptable deformity if removal alone were performed. If your implants were originally for reconstruction or developmental reasons, those items may apply when complications arise.

**What MBS item numbers apply to breast implant removal?**

Four. Item 45548 covers removal without capsulectomy, 45551 covers removal with excision of at least half the capsule and requires a medical indication, and 45553 and 45554 cover removal and replacement following medical complications, with strict eligibility criteria.

**Is a GP referral required for a Medicare rebate?**

Yes. A valid GP referral is required for Medicare to pay any rebate on specialist services, and GP referrals are valid for 12 months. Without a current referral, the rebate does not apply to your consultation or surgery, regardless of whether your clinical situation meets the criteria.

**How much will I pay out of pocket?**

Even with Medicare and private cover, expect meaningful out-of-pocket expense. Medicare typically covers around 75 per cent of the MBS scheduled fee for the surgical component only, and there is usually a gap between the scheduled fee and the actual surgeon's fee. Hospital fees, anaesthetist fees, implant costs for replacement procedures and associated costs add to the total, and a detailed quote is provided after consultation.

Dr Scott J Turner is a Specialist Plastic Surgeon (FRACS). A GP referral is required before an initial surgical consultation under the current Medical Board of Australia framework. To find out whether Medicare may apply to your situation, [contact the practice](https://drturner.com.au/contact-us/) to arrange a consultation, and bring any previous implant records, imaging reports, operation notes and documentation of symptoms. This information is general only and does not guarantee Medicare eligibility, which can only be assessed after consultation, examination and review of your documentation; MBS items and fees can change.