If you’re here, you might be considering breast reduction surgery. Also known as a reduction mammoplasty, breast reduction surgery involves removing fat, skin, and glandular tissue to reduce discomfort associated with large breasts.
Many people choose breast reduction surgery to alleviate pain and alter their appearance. Whether for medical or cosmetic reasons, you should first check if your Medicare covers the operation.
In this guide, I’ll explain everything you need to know about Medicare and breast reduction surgery. I’ll walk you through what Medicare covers, what criteria you must meet, and how to obtain Medicare coverage for breast reduction surgery. Let’s get started.
What is Medicare & What Does it Cover?
Medicare is a universal health insurance scheme designed to provide financial support for medically necessary treatments. It covers operations and procedures deemed essential for improving a person’s physical and/or mental health.
While Medicare is accessible to all Australians (and some foreigners), it does not cover everything. There is a marked distinction between cosmetic and medically necessary procedures. As a result, Medicare breast reduction surgeries are not always covered.
Medicare will assess several criteria before determining whether your breast surgery is covered, including your physical symptoms, evidence of other ineffective treatments, and professional evaluations and recommendations.
If your surgery is approved, Medicare will typically cover around 75% of the cost. By nature, Medicare does not cover the entire cost of the operation, and the amount you pay will vary depending on the surgeon’s fees, hospital costs, private healthcare insurance, and other related charges.
Criteria for Breast Reduction Medicare Coverage
Will Medicare cover a breast reduction? And how do they choose which procedures to cover? Your surgery must involve a medically necessary breast reduction to be covered by Medicare. Breast reduction for purely cosmetic reasons will not be approved.
Here are the criteria that Medicare considers when determining if your breast reduction surgery is covered by their policy:
Pain: You must provide evidence of chronic and persistent pain that directly relates to the size of your breasts and interferes consistently with your day-to-day life. This could include back, neck, shoulder, or head-related pain, as well as skin infections on the underside of the breasts.
Alternative Treatments: Breast reduction surgery should not be your first port-of-call. You must show Medicare that you have attempted previous treatments, such as physical therapy or skin medication, without success before they approve the operation.
Professional Recommendations: You’ll need a referral from your GP before you can visit a plastic surgeon. Once your doctor attests that your breast reduction is medically necessary, your surgeon must then agree and approve the operation.
Impact on Daily Life: Finally, you must show how your breast size negatively affects your life. This could include physical limitations, psychological health issues, persistent pain, skin conditions, or other related mental or physical pain.
Medicare will consider your case based on the above conditions. If you meet these criteria, you will likely qualify for Medicare-covered breast reduction surgery.
How Do I Get Medicare Coverage for Breast Reduction Surgery?
If you fulfil the criteria, you can claim financial help from Medicare. I’ll now give you step-by-step instructions on how to obtain Medicare coverage for your breast reduction procedure:
Familiarise Yourself with Medicare: Make sure you’re familiar with Medicare’s rules and criteria before proceeding with your surgery. You can always come back to this article if you’re unsure whether your breast reduction is covered by Medicare.
Initial Consultation: Speak with your GP to discuss your symptoms and concerns. If they deem your situation medically necessary, they can provide documentation and refer you to a plastic surgeon.
Specialist Assessments & Tests: Consult a plastic surgeon for further assessments. They may require you to undergo certain medical tests like X-rays or scans to demonstrate the negative effects of your breast size. They will then provide another professional opinion as to whether your breast reduction surgery is medically necessary.
Discuss Additional Costs: Make sure you understand the extra fees involved in breast reduction surgery. These could include hospital charges, surgeon fees, anaesthetist fees, and other costs that Medicare may not cover. As I mentioned earlier, Medicare will usually cover around 75% of the total costs.
Submit Documents to Medicare: Contact the Medicare support team and provide the relevant information to start your claim. This includes your personal details, policy number, referral documents, and hospital forms. Medicare will then assess your case and respond accordingly.
Seek Private Health Insurance: Even if your claim is successful, you’ll still have to pay out-of-pocket costs. This is where private health insurance can be useful, as they may be able to cover the remaining surgery costs.
Dr Birch Recommends: I suggest keeping a record of your symptoms, including when they arise and how they affect you, to strengthen your case to your insurer.
Medicare Item Numbers for Breast Reduction
In Australia, Medicare categorises medical procedures using specific numbers. It’s important to know which item number your procedure is associated with in order to ensure your reimbursement process is as smooth as possible. It will also allow you to check whether your private health insurance covers your operation.
The Medicare item numbers related to breast reduction surgery, alongside their legal definitions as defined by Medicare, are as follows:
Item 45520: “Reduction mammaplasty (unilateral) with surgical repositioning of nipple, in the context of breast cancer or developmental abnormality of the breast.”
Item 45522: “Reduction mammaplasty (unilateral) without surgical repositioning of the nipple:
(a) excluding the treatment of gynaecomastia; and
(b) not with insertion of any prosthesis.”
Item 45523: “Reduction mammaplasty (bilateral) with surgical repositioning of the nipple: (a) for patients with macromastia who are experiencing pain in the neck or shoulder region; and (b) not with insertion of any prosthesis."
These procedures are not covered by Medicare when they are “associated with a service to which item 31512, 31513 or 31514 applies on the same side (H)”.
Private Health Insurance for Breast Reduction Surgery
While Medicare Australia can cover most of your breast reduction surgery, you can also claim the remaining costs back via private health insurance.
In my experience, most private health insurers cover treatments recognised by Medicare. This is why the item numbers matter, as you can strengthen your claim to your insurer if your surgery is assigned one of the three Medicare item numbers.
Your private healthcare insurance can be a valuable companion for breast reduction surgeries. It not only covers the extra costs, but it also gives you more flexibility about choosing hospitals and shorter waiting times. For these reasons, I advise my patients to register for private health insurance before they undergo a breast reduction procedure.
Book a Consultation with Dr Theo Birch Today
Breast reduction surgery is often essential to improving your physical and mental well-being. If you’re unhappy with the size of your breasts and want to take the weight off your shoulders, contact Dr Theo Birch today to book a no-obligation consultation.
Contact our clinic today to take the first step towards achieving a more
confident and comfortable you.
Jade Chapman – Nurse Practitioner
FAQs
Is Breast Reduction Surgery Covered by Medicare in Queensland?
Medicare covers breast reduction surgery in Queensland, provided you meet certain criteria. Your breast reduction procedure must be deemed medically necessary by your GP and a plastic surgeon. You’ll also have to demonstrate how the size of your breasts negatively impacts your life and show that you’ve tried previous treatments that did not work.
Can Private Health Insurance Cover the Costs of Breast Reduction Surgery Not Covered by Medicare?
Yes, your private healthcare insurance can cover the remaining costs of breast reduction surgery. Medicare only covers 75% of the total costs. Additional charges, such as surgeon and hospital fees, must be paid by the patient. However, these can be reclaimed from private health insurers.
What are the Conditions for Medicare to Cover Breast Reduction Surgery?
To be eligible for Medicare breast reduction surgery, you’ll need to demonstrate that your breast size negatively affects your daily life. A GP and plastic surgeon must agree that the procedure is medically necessary, and you must have tried other treatments before you attempt a surgery.
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