Last Updated May 2025
For many patients considering breast implant removal surgery, understanding Medicare coverage options is a crucial part of the planning process. At Dr Scott J Turner’s clinics in Manly (Northern Beaches) and Double Bay, we receive numerous inquiries about Medicare eligibility for explant procedures. This comprehensive guide will help you understand when Medicare rebates apply and what criteria you need to meet.
Understanding Medicare Coverage for Breast Implant Removal
Medicare in Australia may provide rebates for breast implant removal surgery, but only when the procedure is deemed medically necessary. Medicare does not cover purely cosmetic procedures, meaning you won’t receive rebates if you’re simply changing your mind about having implants.
IMPORTANT NOTE: Dr Turner does not offer free breast implant removal surgery. Medicare and private health insurance may offer a partial subsidy for procedures performed in private practices, but there will still be significant out-of-pocket expenses. Public hospitals may offer free plastic surgery for some procedures, but waiting periods can extend to years.
Medical Conditions That Qualify for Medicare Coverage
To qualify for Medicare rebates, your breast implant removal must be considered medically necessary due to complications such as:
- Capsular contracture with disfigurement (hardening of scar tissue around the implant)
- Implant rupture or leakage confirmed through diagnostic imaging
- Infection caused by the implants
- Implant extrusion (where the implant becomes exposed through the skin)
- Interference with breast cancer diagnosis or treatment
- Siliconoma or granuloma formation (inflammatory reactions to silicone)
- Migration of implant from its original position
- Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) (a rare type of lymphoma associated with textured implants)
- Breast Implant Illness (BII) (a collection of symptoms some patients attribute to their breast implants)
Medicare Item Numbers for Breast Implant Removal
The Medicare Benefits Schedule (MBS) uses specific item numbers for breast implant removal procedures:
Item 45551 – Removal with Capsulectomy (No Replacement)
This covers breast implant removal with excision of at least half of the fibrous capsule, without insertion of a new implant.
Requirements include:
- The excised specimen must be sent for histopathology
- The volume removed must be documented in the report
Item 45548 – Basic Implant Removal
This covers straightforward breast implant removal as an independent procedure.
The Patient Journey: Obtaining Medicare Coverage
Step 1: GP Referral
Start with a visit to your GP to discuss your symptoms. A valid referral addressed to Dr Scott J Turner is essential for Medicare eligibility. GP referrals are valid for 12 months.
Step 2: Specialist Consultation
During your initial consultation with Dr Scott Turner, he will:
- Assess your medical history
- Perform a physical examination
- Document symptoms and complications
- Determine if you meet Medicare criteria
- Discuss potential surgical approaches
Step 3: Diagnostic Investigations
Depending on your symptoms, diagnostic investigations may be required to confirm medical necessity:
- Ultrasound scans
- MRI to confirm rupture, migration, or other complications
- Photographic documentation
Step 4: Documentation for Medicare
Comprehensive documentation is crucial for Medicare claims:
- Detailed surgeon’s report outlining medical necessity
- Diagnostic imaging reports
- Photographic evidence
- Documentation of failed conservative treatments (if applicable)
Step 5: Surgery and Claim Submission
Following surgery, Dr Turner’s team will assist with Medicare claim submission. This includes providing all necessary documentation for your claim.
Private Health Insurance Considerations
If you qualify for Medicare (meaning you have an eligible MBS item number), your private health insurance may provide additional benefits:
- Coverage for hospital accommodation and theatre fees
- Contributions toward anesthetist fees
- Potential coverage for some out-of-pocket expenses
You will need appropriate hospital cover (typically Silver or Gold tier). Always check directly with your private health fund regarding your specific policy coverage, as requirements vary between insurers.
Understanding Costs
The cost of breast implant removal surgery varies depending on:
- Complexity of the procedure
- If implant replacement or mastopexy is part of the surgery
- Hospital fees and anesthetist costs
Even with Medicare rebates, patients should expect out-of-pocket expenses. Dr Turner’s team will provide a detailed quote following your consultation, outlining all anticipated costs.
Important Medicare Coverage Notes
- Medicare only covers procedures that address medical complications, not purely cosmetic changes such as simply wanting smaller implants.
- For patients with BII symptoms, documentation of physical complications alongside these symptoms can strengthen your case for Medicare eligibility.
- Medicare typically covers approximately 75% of the MBS scheduled fee for the surgical component only, not including hospital fees, anesthetist costs, or other associated expenses.
- MBS item codes are reviewed regularly and can change. If you currently meet eligibility criteria, it’s advisable to proceed with surgery sooner rather than later.
Next Steps
- Obtain a Medical Referral
A referral from your GP or specialist is essential for Medicare rebates. - Book a Consultation
Schedule a comprehensive consultation with Dr Scott J Turner to assess your situation and determine Medicare eligibility. - Verify Private Health Insurance Coverage
Contact your health fund with potential MBS item numbers to confirm your coverage. - Gather Required Documentation
Collect all relevant medical records, imaging reports, and documentation of symptoms.
For more information or to book your consultation, contact Dr Turner’s team at 1300 437 758 or email [email protected].
Visit our Manly clinic or Double Bay clinic to discuss your options with Dr Scott J Turner, Specialist Plastic Surgeon.
Disclaimer: All surgery contains risks. The information provided is general in nature. For specific information concerning your specific medical condition, please book a consultation with Dr Turner.
