Will Medicare Cover My Breast Lift?

How to Get Medicare and Insurance to Pay for Breast Lift Surgery

Can You Get Medicare to Cover Breast Lift?

Many patients get coverage for breast lift through Medicare in Australia using the popular Medicare item numbers 45558 and 45556. 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 you are getting breast lift surgery due to purely cosmetic reasons only, Medicare won’t pay for it.

PLEASE NOTE – Dr Turner does not offer FREE Breast Lift 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.

Dr Scott Turner is a specialist plastic surgeon in Sydney who performs a breast lift – find out more about his Breast Lift Surgery and look at the before and after results of past Breast Lift surgeries.

What are the Criteria for Getting Medicare for Breast Lift?

There are many health concerns that can help you qualify for a Breast Lift surgery and make it a medical necessity including:
  • At least two-thirds of the breast including nipples lie below the inframammary fold (IMF).
  • You are experiencing chronic breast skin infections and rashes due to excess breast skin.
  • If the weight of your breasts is impacting your health and quality of life.

Quick Facts about Medicare Cover for Breast Lift

  • Medicare only covers breast lift surgery if it is medically necessary.
  • Medicare does not cover elective cosmetic breast lifts.
  • Patients can get coverage under a Medicare plan if it is deemed as a medical necessity, they have a valid referral and meet strict criteria.
Read our blog Will Medicare Cover My Surgery?

What is Breast Lift Surgery?

A breast lift surgery or Mastopexy is a surgical procedure that involves the removal of excess skin from the breasts along with reshaping and tightening of the breasts to make them sit higher. It is primarily considered to be a cosmetic surgical procedure but sometimes it is deemed as a medical necessity. In such cases, Medicare and/or Private Health insurance may contribute to a portion of your breast lift quote.

Why Should I Consider a Breast Lift?

If you are experiencing skin infection, redness, irritation, and chafing due to rubbing of the excess breast skin or folds, the procedure may be right for you.

You’ll Need a Medical Referral with Documented Concerns

In order to get Medicare to fund the costs of the surgery, 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, including skin infections and pain. While consulting with your GP, it is worth discussing your symptoms to ensure the clinical need is documented in your referral.

How Do You Qualify for Medicare Rebate for Lift Surgery? – MBS Item Numbers

These MBS Item Numbers may be applicable for Breast Lift Surgery:

Medicare Item Number 45558

Correction of bilateral breast ptosis by mastopexy, if:

(a) at least two‑thirds of the breast tissue, including the nipple, lies inferior to the inframammary fold where the nipple is located at the most dependent, inferior part of the breast contour; and
(b) photographic evidence (including anterior, left lateral, and right lateral views), with a marker at the level of the inframammary fold, demonstrating the clinical need for this service, is documented in the patient’s notes.

Applicable only once per lifetime

(NOTE – a recent medicare change means you NO longer have to have a child between the ages of 1 to 7 to meet the criteria for these Breast lift item numbers)

Medicare Item Number 45556

Breast ptosis, correction of (unilateral), in the context of breast cancer or developmental abnormality, if photographic evidence (including anterior, left lateral, and right lateral views) and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient’s notes.

Applicable only once per occasion on which the service is provided.

Will Medicare Cover Breast Lift Surgery for Medical Reasons? – Meeting MBS Criteria

If you have required documentation for breast Lift surgery and you meet the Medicare criteria, you may 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;

Correction of bilateral breast ptosis by mastopexy, if:

(a) at least two‑thirds of the breast tissue, including the nipple, lies inferior to the inframammary fold where the nipple is located at the most dependent, inferior part of the breast contour; and
(b) photographic evidence (including anterior, left lateral, and right lateral views), with a marker at the level of the inframammary fold, demonstrating the clinical need for this service, is documented in the patient’s notes

Breast ptosis, correction of (unilateral), in the context of breast cancer or developmental abnormality, if photographic evidence (including anterior, left lateral, and right lateral views) and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient’s notes.

What are the Medicare Breast Lift Surgery Criteria in Australia?

People who meet the conditions associated with these item numbers qualify for Medicare rebates in Australia: 45558, 45556.

How Do I Qualify for Medicare Coverage for Breast Lift Surgery?

Medicare will provide coverage for a breast lift if you can provide evidence of medical necessity. In order to get Medicare funding for breast lift, you need to contact your GP or surgeon to assess the degree of breast sagging aka breast ptosis as well as nipple location.

Your nipple needs to lie significantly below the inferior breast crease (IMF). Alongside that, two-thirds of the breast lies below the inframammary fold. Once these two requirements are confirmed, the surgeon will take photographs to account as evidence that is required by Medicare funding.

Your detailed medical history will be taken into account.

Will Health Insurance Help Cover the Cost of Breast Lift 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 factors will change/affect your claim.

If you qualify for Medicare you may also be eligiblefor a subsidy on the Breast Lift Surgery from your Private Health Insurance Provider. This only applies if your condition meets the criteria for Medicare Item Numbers 45556 and 45558 and you have the right level of coverage. Please contact your health fund.

Why is Medicare for Breast Lift Surgery Confusing for Many Patients Seeking Plastic or Cosmetic Surgery?

All the confusion surrounding breast lift surgery can get quite overwhelming. The confusion is primarily due to the fact that breast lift surgery is a highly customised procedure that depends on the individual and their goals.

Rebates are available for a reconstructive procedure or what is considered ‘medically necessary. Not all breast lift procedures will fall under this category. Only your GP or Plastic surgeon will help you figure out whether you are an ideal candidate for the procedure or not.

When it comes to plastic surgery, Medicare is very clear about not covering non-therapeutic cosmetic surgery and plastic surgery procedures.

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 lift surgery, it is best to get the procedure sooner rather than later.

How Much Will My Breast Lift Surgery Cost If Self-Funded?

The cost of getting a breast lift surgery done by a specialist plastic surgeon in Australia is dependent on a variety of different factors such as geographic area, expertise, the experience of the surgeon, and the goals of the surgery. The variation in the cost can be attributed to the customised nature of the procedure and the desired outcome.

To determine the exact quote, you can come in for a consultation with Dr Turner or reach out to our team. Our team will provide an estimated quote as well as help you understand the risks associated with the surgery and help you check your eligibility for coverage by MBS or your health fund.

In order to check your eligibility to claim a Medicare rebate for your Breast Lift 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. Visit the surgical costs page for more information and download the guide.

Can I Use My Super Fund to Pay for Breast Lift Surgery?

In certain cases, you can use your super fund to pay for the breast lift surgery. Prior to requesting an early release of funds, it is important to note that each application for early release of super fund 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 Lift Medicare FAQs

Here is a list of frequently asked questions we get regarding breast lifts and Medicare rebates:

Can you get a breast lift through Medicare?

Yes, you can get a breast lift covered by Medicare if it is deemed a medical necessity by your doctor and you meet the strict criteria. Medically necessary situations include reconstruction after a mastectomy or reduction to help with the pain. You have to meet the criteria of popular Medicare item numbers 45558 and 45556.

Does Medicare cover breast reduction and lift?

Medicare will cover breast reduction and lift if they are deemed as a Medical necessity by your surgeon and GP and you meet the Medicare criteria.

How do you qualify for a breast reduction and lift?

You have to meet the criteria of the following MBS codes for reduction and lift:

MBS Codes for Breast Lift

  • 45558 Breast Lift Mastopexy – Bilateral (both breasts)
  • 45556 Breast Lift Mastopexy – Unilateral (one breast only)- payable only once per occasion

MBS Codes for Breast Reduction

45523 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 the 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 the insertion of any prosthesis

What is considered medically necessary breast surgery?

If your breasts are causing any medical problems such as pain, skin chafing, irritation, and infections, and the breast lift is considered to be the only way to address these issues, it will be deemed as a medical necessity.

Who decides if a breast lift is medically necessary?

Your general practitioner can help you determine whether the procedure is medically necessary or not. You’ll have to submit the required documents and photographic evidence to Medicare and they will make the final call.

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Next Steps

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 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 early for your in-person consultation.
  • You are welcome to bring a friend or relative to help consider the information and discuss your options.
  • 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?

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 1300 437 758 to arrange your surgeon consultation in Sydney.

Email us for more information: [email protected]