Does Medicare Cover Breast Reduction Surgery?

Are you thinking about breast reduction surgery for heavy, drooping breasts? Are you wondering if your private health insurance covers the cost? Or if you can claim a Medicare rebate on some or all of the costs? Medicare may offer rebates on breast reduction or breast lift procedures. However, to claim a Medicare rebate or private insurance coverage for potential breast reduction surgery, there is strict criteria that you will need to meet. You should also be aware that Medicare codes and rebate eligibility criteria will change quickly and sometimes without notice possibly effecting your claim.

How Do You Get a 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 the age of your youngest child and 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. Some Super Funds also allow early release of funds to use for breast reduction surgery.

Medicare Cover Breast Reduction Surgery

Reasons for wanting Breast Reduction Surgery may include:

  • Chronic skin infections
  • Overcome back pain, neck pain or shoulder pain related to breast weight, breast volume or breast ptosis
  • Other breast-weight related health conditions that impact your health and quality of life.

Will Medicare Cover Breast Reduction Surgery?

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 strict Medicare criteria.

Not all patients will meet this criteria:

  • Your GP or plastic surgeon will need to assess the degree of breast ptosis (sagging and nipple location)
  • They will determine the detrimental impacts to your health that breast volume, skin chaffing and heavy breast weight may have
  • Your GP is generally your first stop, before requesting a referral to the plastic surgeon of your choice

With relation to Medicare rebates or breast reduction mammoplasty and the age of your youngest child, current as of 2017 (subject to sudden Medicare rebate changes) your child must be in between the ages of 12 months and 7 years old.

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.

But here’s what you need to know about funding your surgery or being eligible for a partial rebate from Medicare.

Why is the Medicare Rebate Question 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

Medicare Cover Breast Reduction Surgery

Medicare Rebates are subject to unpredictable and sudden changes.

Medicare codes can suddenly be eliminated from the 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:

  • Facial or nose reconstructive plastic surgery (accident or trauma)
  • Rhinoplasty (corrective) breathing impaired by nose injury, deviated septum or other type of nasal structural abnormality
  • Breast reconstruction surgery following a mastectomy
  • Breast prosthesis following a mastectomy
  • 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)
  • Breast lift or breast reduction surgery (specific criteria)
  • Breast asymmetry

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 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. To be eligible to claim Medicare item 45520, you will need to visit your GP for a referral to have a consultation with Dr Rubinstein who is one of Melbourne’s Leading Breast Reduction Surgeons.

Dr Craig Rubinstein performs custom Breast Reduction, Breast Lift Surgery, Asymmetry Correction and Tummy Tuck Surgery

Medicare Cover Breast Reduction Surgery

Please Contact Dr.Rubinstein’s office to book a consultation or enquire about further information regarding plastic surgery procedures.

Dr. Craig Rubinstein’s affiliations include: