Can I claim my Breast Lift on Medicare?
Patients always ask, will Medicare pay for my Breast Lift surgery? – Your droopy or deflated breasts that can cause rashes or infections can be greatly relieved by a breast lift or Mastopexy surgery.
So will it be medically covered? The answer is MAYBE – Medicare MAY offer rebates on breast lift or breast reduction procedures, IF you meet the special criteria and conditions – see below.
Are you wondering if your private health insurance will cover you and contribute to the costs?
To claim private insurance coverage for potential breast lift surgery you need to be eligible for the medicare item number. You will also need to deal directly with your health fund regarding funding contributions for your Breast Lift surgery to see if you are eligible under your level of cover.
Considering Breast Lift Surgery? Get the Breast Lift Surgery guide!
Some Super Funds also allow early release of funds to use for breast lift surgery under strict criteria.
Popular Reasons for wanting Breast Lift Surgery include
- Significant breast ptosis or sagging – at least two-thirds of breast tissue is beneath the inframammary fold – the breast crease under the breast.
- Chronic skin infections and rashes
- Other breast-weight related health conditions that impact your health and quality of life
How Do You Qualify for Medicare Rebate for Breast Lift Surgery?
To qualify for a rebate from Medicare you will need to meet certain Medicare criteria, for either a breast reduction and or breast lift surgery.
Your eligibility will depend on the age of your youngest child and/or your degree of breast ptosis (breast sagging).
These MBS Codes may be applicable for Breast Lift Surgery
- 45558 Breast Lift Mastopexy – Bilateral (both breasts)
- 45556 Breast Lift Mastopexy – Unilateral (one breast only)- payable only once per occasion
Full MBS Item Number Description
- 45558 Breast ptosis, correction by mastopexy of (bilateral), 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) if the patient has been pregnant-the correction is performed not less than 1 year, or more than 7 years, after completion of the most recent pregnancy of the patient; and (c) 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 notes Applicable only once per lifetime (Anaes.) (Assist.)
- 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 notes – Applicable only once per occasion on which the service is provided
For more information Download Medicare and Health Insurance Guide!
Will Medicare Cover Breast Lift Surgery for medical reasons? – MBS Criteria
Breast surgery may be warranted for medical reasons as well as potential improvements in your well-being.
To be eligible for a Medicare rebate the surgery will need to be deemed medically necessary by meeting these strict Medicare criteria. Not all patients will meet these criteria:
- Your GP or plastic surgeon will need to assess the degree of breast ptosis (sagging and nipple location) – the nipple must be significantly beneath the inframammary fold (two thirds below crease with nipple at the lowest point) and photographic evidence is required
- Another strict criteria is that IF you have been pregnant – your youngest child must be between the ages of 1 year and 7 years old at the time of surgery. If you have not been pregnant this does not apply.
- You will need to get and hold a current medical referral at the time of surgery – A Referral from a GP lasts 12 months and a referral from a specialist lasts 3 months.
Find out about the medicare criteria for breast reduction surgery on our blog page.
How to Research to find out if Medicare and the MBS Covers Your Surgery Procedure
- The MBS is a very comprehensive list, which can be downloaded in its entirety.
- Alternatively, you can just use the search function to find your desired procedure.
- If there is no valid Medicare code to your procedure, your health fund won’t cover the procedure either
To view the MBS schedule listing Medicare rebates, you can visit MBS online. So if you have sagging breasts and would like more information, contact your GP.
Why is Medicare for Breast Surgery confusing for many patients seeking Plastic or Cosmetic Surgery?
That’s because it varies depending on the individual and the procedure required, Medicare will sometimes offer only a minor rebate on some procedures. Rebates are generally only available for reconstructive breast lift plastic surgery or what is considered ‘essential’ surgery. Not all breast surgery will fall under this category. Breast lift and breast reduction may be considered for some patients. Breast Augmentation is rarely covered.
When it comes to plastic and cosmetic surgery, the Medicare rebate guidelines are very clear, Medicare will not cover non-therapeutic cosmetic surgery and non-therapeutic plastic surgery’ procedures.
A Breast Lift Can Have Life-Changing Effects
There are many benefits to having breast lift surgery and most breast lift patients will enjoy many lifestyle benefits after a breast lift. This may include feeling more confident, better health and looking better in clothes. Lessening the saggy breasts also means you’ll have improved posture. Having less sag makes keeping fit a lot easier and you will also look slimmer.
Medicare Rebates are subject to change and review.
MBS Item codes can be changed or eliminated from the Medicare rebate schedule. If your breast lift surgery is currently eligible for a Medicare rebate, it may be best to perform your procedure sooner rather than later.
Other Plastic Surgery that can be covered by Medicare and Private Health Insurance:
Other plastic surgery procedures that Medicare may cover in relation to eligibility for a rebate.
- Breast lift or breast reduction surgery (specific criteria apply)
- Breast asymmetry
- Breast reconstruction surgery following a mastectomy
- Breast prosthesis following a mastectomy
- Facial or nose reconstructive plastic surgery (for accident or trauma)
- Septoplasty or Rhinoplasty (corrective nose surgery) breathing impaired by nose injury, deviated septum or other types of nasal structural abnormality
- Body lift surgery (skin ‘tightening’ of excess skin) following rapid weight loss, or
- Bariatric weight loss surgery for obesity
- Eyelid lift surgery (blepharoplasty)
Medicare currently covers only medical and surgical procedures that are clinically necessary for your health.
Medicare does NOT cover elective plastic surgery or cosmetic procedures for purely cosmetic reasons, such as liposuction or breast enlargement.
To be eligible to claim a Medicare item, you will need to visit your GP for a referral before surgery with Dr Craig Rubinstein who is one of Melbourne’s Leading Breast Lift Surgeons.