Can I claim my Breast Reduction on Medicare?
Patients always ask, will Medicare pay for my Breast Reduction surgery? – There is significant research that indicates women’s health and post-pregnancy conditions, such as neck pain, shoulder pain, rashes or infections can be greatly relieved by breast reduction surgery (Reduction Mammoplasty) of their heavy, sagging & droopy breasts.
So will it be covered? The answer is MAYBE – Medicare MAY offer rebates on breast reduction or breast lift procedures, IF you meet the special criteria and conditions – see below.
Are you wondering if your private health insurance also covers the cost? To claim a Medicare rebate or private insurance coverage for potential breast reduction surgery, there are strict criteria that you will need to meet. You should also be aware that Medicare codes and rebate eligibility criteria can change and possibly affect your claim.
Some Super Funds also allow early release of funds to use for breast reduction surgery.
Considering Breast Reduction Surgery? Get the Breast Reduction Surgery guide!
Reasons for wanting Breast Reduction Surgery may include:
- Overcome back pain, neck pain or shoulder pain related to breast weight, breast volume or breast ptosis (sagging)
- 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 Reduction Surgery?
To qualify for a rebate from Medicare you will need to meet certain Medicare criteria, for either breast reduction and or breast lift surgery. Your eligibility may depend on assessing your degree of breast ptosis (breast sagging).
You can also liaise directly with your chosen health fund regarding funding contributions for a mammoplasty to see if you are eligible.
These MBS Codes may be applicable for Breast Reduction
- 45523 Breast Reduction Surgery Bilateral (both sides) where strict MBS criteria applies – see below
- 45520 Breast Reduction Surgery with surgical repositioning of the nipple – Unilateral (for each Single side)
- 45522 Breast Reduction Surgery without repositioning of the nipple – Unilateral (for each single side)
Full MBS Item Number Description
- 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 (Anaes.) (Assist.)
- 45520 Reduction mammaplasty (unilateral) with surgical repositioning of the nipple, in the context of breast cancer or developmental abnormality of the breast (Anaes.) (Assist.)
Will Medicare Cover Breast Reduction Surgery for medical reasons? – MBS Criteria
Breast reduction surgery may be warranted for medical reasons as well as potential improvements in well-being such as heavy, ptotic breasts that cause chronic health conditions such as back and neck pain.
To be eligible for a Medicare rebate the surgery will need to be deemed medically necessary by meeting the 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 beneath the inframammary crease
- They will determine the detrimental impacts on your health that breast volume, skin chaffing and heavy breast weight may have
- 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.
- NOTE – You cannot have a breast reduction item number if you are having a breast implant
For more information Download Medicare and Health Insurance Guide!
How to Research to See 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 procedure.
- Further, 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, heavy breasts that are causing health problems and would like more information, contact your GP.
Why is the Medicare Rebate for Breast Surgery Confusing for Most Patients Seeking 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 reduction 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.
When it comes to plastic and cosmetic surgery, the Medicare rebate guidelines are very clear, Medicare will not cover:
- non-therapeutic cosmetic surgery
- non-therapeutic plastic surgery’ procedures
Breast Reduction Can Have Life-Changing Effects
There are many benefits to having breast reduction surgery and most breast reduction patients will find many new freedoms that are presented after a breast reduction. This may include picking up the children more easily, being able to jog again and sleeping better at night. Lessening the weight of heavy breasts also means you’ll have improved posture. Having less volume makes keeping fit a lot easier and you will also look slimmer.
Visit the Breast Reduction Surgery Page
Medicare Rebates are subject to change and review.
MBS Item codes can be changed or eliminated from the Medicare rebate schedule. If your breast reduction surgery is currently eligible for a Medicare rebate, it may be best to perform your procedure sooner rather than later.
Other plastic surgery procedures that Medicare may cover in relation to eligibility for a rebate.
Medicare may sometimes offer partial rebates on:
- 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 surgery
- 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 to have a consultation with Dr Craig Rubinstein who is one of Melbourne’s Leading Breast Reduction Surgeons.
Dr. Craig Rubinstein’s affiliations include: