How to get Medicare and Insurance to pay for Breast Implant Removal
Can you get Medicare to cover Breast Implant Removal?
Many patients get coverage for breast implant removal through Medicare in Australia using the popular Medicare item numbers 45554, 45551, and 45548. 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 and not because you simply changed your mind and decided to get the implants out.
Dr Scott Turner is an experienced Plastic Surgeon and Sydney Breast Surgery Expert – find out more about his Breast Surgery procedures and look at the before and after results of past Breast Implant Removal surgeries.
CLICK to Download Dr Scott Turner’s Breast Implant Removal Guide
What are the criteria for getting Medicare for Breast Implant Removal – Explant or Enbloc Surgery?
There are many health concerns that help you qualify for breast implant removal surgery and make it a medical necessity including:
- You are dealing with painful capsular contracture with disfigurement
- You are faced with a breast implant rupture
- Any kind of infection caused by implants makes you eligible for the surgery
- Implant extrusion – where the surface of the implant or tissue expander comes through the skin and becomes exposed
- Your implants are interfering with the diagnosis of breast cancer
- You are dealing with siliconoma or granuloma
Quick Facts about Medicare Cover for Breast Implant Removal
- Medicare only covers breast implant removal surgery if it is medically necessary
- Medicare does not cover purely aesthetic breast implant removal procedures
- Patients can get coverage underMedicare if it is deemed as a medical necessity, you have a valid referral and meet strict criteria
What is Breast Implant Removal Surgery?
Breast Implant Removal is a surgical procedure that involves taking out silicone or saline breast implants. It can be done for both medical and aesthetic reasons. Some people simply don’t get used to the new look of the breasts after a breast augmentation surgery while others are faced with complications.
Why Should I Consider Breast Implant Removal?
People get their implants removed all the time. All of them have different reasons for doing so. Some of the reasons you might want to consider breast implant removal are:
- You no longer like the look of your larger breasts and want to get the implants removed
- Your heavier breasts are leading to pain in the back and neck area
- You are experiencing leaking of the breast implants
- You have calcium build-up around the implants
- Your body is generating an autoimmune response to the implants
- You are experiencing the shifting and moving of one or both implants
- You are suffering from breast implant illness or worried about BIA ALCL
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 your surgeon or after the first appointment.
It is important to demonstrate medical necessity. 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 Implant Removal be covered by Medicare?
The answer to this is ‘MAYBE’ – Medicare offers rebates on breast implant removal if you meet the special criteria and conditions as listed below.
How do I qualify for Medicare coverage for Breast Implant Removal?
In order to qualify for a rebate from Medicare, you have to meet the criteria specified by them.
The Medicare Benefits Schedule (MBS) uses a numbered list of services subsidized by the Australian Government. Breast implant removal surgery falls into the third category of procedures – therapeutic procedures, and a subgroup of plastic and reconstructive surgery.
MBS ITEM NUMBERS FOR IMPLANT REMOVAL SURGERY ARE:
45554 – Breast Prosthesis Removal and Replacement with the formation of the new pocket
45551 – Breast Prosthesis Removed with Capsule Excision
45548 – Breast Prosthesis Removal
Your surgeon and GP needs to verify that you are getting the surgery done for medical reasons instead of medical ones and list all the complications you are experiencing because of it- pain, capsular contracture, implant rupture, leaking implants, calcium build-up, necrosis, shifting of implants, and autoimmune response (some individuals experience only one of these complications while others experience a combination of above).
What are the MBS Item Numbers for Medicare Rebate for Breast Implant Removal Surgery? – Popular MBS Codes
Medicare Item Number 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, if:
(a) either:
(i) it is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity; or
(ii) the original implant was inserted in the context of breast cancer or developmental abnormality; and
(b) the excised specimen is sent for histopathology and the volume removed is documented in the histopathology report; and
(c) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes
Medicare Item Number 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.
Medicare Item Number 45548
BREAST PROSTHESIS, removal of, as an independent procedure.
What are the Medicare Breast Implant Removal criteria in Australia?
People who meet the conditions associated with these item numbers qualify for Medicare rebates in Australia: 45551, 45554, 45548.
Will private health insurance help cover the cost of Breast Implant Removal Surgery?
You need to meet strict criteria for your insurance or Medicare to help pay for the surgery. It is important to be fully aware of Medicare item numbers and rebate eligibility criteria as these two factors can change or affect your claim.
If you qualify for Medicare you may also be eligible for rebates on the Breast Implant Removal surgery from your Private Health Insurance Provider. This only applies if your condition meets the criteria for Medicare Item Number.
You will need the right level of cover For some funds, Bronze Hospital cover is enough but Silver Hospital cover might be required. 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 Implant Removal 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 many patients, breast implant removal 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. Pain, capsular contracture, implant rupture, leaking implants, calcium build-up, necrosis, shifting of implants, and autoimmune response related to implants 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 implant removal surgery, it is best to get the procedure sooner rather than later.
Will my private health fund cover my breast implant removal 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 Implant Removal Surgery cost if self-funded?
The cost of having a Breast Implant Procedure performed by a Specialist Plastic Surgeon in Australia varies depending on the geographical location, experience and expertise of the surgeon, and your reasons for getting the surgery.
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 Implant Removal 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 on 1300 64 11 99, who are available to answer your questions. Please visit the surgical costs page for more information and download the procedure guides.
Can I Use My Super Fund to pay for Breast Implant Removal Surgery?
Some patients use their own super fund to pay for their breast implant removal 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
FAQs about Medicare for Breast Implant Removal Surgery
How can I get Breast Implant Removal with Medicare?
- Many people get breast implant removal surgery partly covered by Medicare using the popular Medicare item numbers 45554, 45551, and 45548. If your surgeon can verify the medical necessity, you might be able to get the rebate.
Why do women get breast implant removal surgery?
- You can get breast implant removal for both aesthetic and medical reasons. You might want to get the implants out because you don’t like the look of larger breasts anymore or you are experiencing complications.
Do I need a medical referral to get Medicare for my Breast Implant Removal?
- Yes, you need a medical referral to get Medicare for Breast Implant Removal. You can get a referral from a GP or Medical Specialist.
In Summary
If you need breast implant removal surgery and are hoping to get a Medicare rebate, it is important to keep in mind that:
- Medicare will not cover the explant surgery done for cosmetic reasons
- Medicare will only cover breast implant removal surgery when it is deemed medically necessary by your doctor
- Medically necessary situations generally include pain, capsular contracture, implant rupture, leaking implants, calcium build-up, necrosis, shifting of implants, and autoimmune response related to implants
- The overall cost of breast implant removal depends on a variety of different factors including your plan, surgeon, and geographical location
About Dr Scott Turner FRACS (Plas) – Specialist Plastic Surgeon
Dr Scott J Turner has spent a lifetime acquiring the qualifications, education, training, and hands-on surgical experience to perform superior cosmetic plastic surgery to give you natural, beautiful results and the improved sense of well-being you want. He is one of the top Specialist Plastic Surgeons with a Breast and Body Surgery focus in New South Wales.
Achieving this personal goal requires not only in-depth knowledge of human anatomy and refined surgical techniques but an ongoing commitment to learning the latest procedures around the world. This is why Dr Turner regularly attends both local and international surgeon meetings – discussing these advances with the leaders around the world in order to offer you the most natural, effective and safest surgical procedures. He is a committed board member of ASAPS – Australia Society of Aesthetic Plastic Surgeons
Dr Turner and his highly trained staff will do everything to ensure that you are fully informed, while providing exceptional, world-class cosmetic plastic surgery, in a personal and caring environment.
Next Steps
Always Do Your Research
- Download a Procedure Guides 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 medical referral is helpful but NOT essential for purely cosmetic consultations.
- 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 with Dr Scott
- 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, medical payment plans and paying for your surgery
- Request more information about the procedure – call or contact us
How to Book Your Consultation with Dr Turner
- You can book your initial consultation with Dr Turner 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 Patient Care team – BOOK A CALENDLY CALL
Contact us or call on 1300 641 199 to arrange your surgeon consultation in Sydney or Newcastle.
Email us for more information: [email protected]