Does Medicare Cover Breast Reduction Surgery?

Criteria and Conditions for Medicare Cover for Breast Reduction Surgery

If you’re here, you might be considering breast reduction surgery procedure and wondering about the financial implications, including Medicare coverage. Medicare, the public health insurance system in Australia, provides coverage for a wide range of medical treatments and procedures, including some cosmetic surgeries when they are deemed medically necessary. Medicare is designed to provide all Australian residents with affordable, accessible, and high-quality health care. This includes coverage for hospital care, specialist visits, prescription medications, and certain surgeries. But, like any health insurance program, the specifics of what is covered can be complex and confusing. So, when it comes to specific procedures like breast reduction surgery, it is essential to understand the details of what Medicare covers.

It’s important to note that Medicare does not cover all procedures. Certain conditions and criteria must be met for Medicare to provide coverage. This is where understanding the intricacies of the Medicare system, including item numbers and specific criteria for coverage, becomes crucial.

Specialist Plastic Surgeon Dr Jake Lim performs plastic and reconstructive surgery, including breast reduction procedures. Patients seek his services not just for aesthetic purposes, but also for medical reasons, such as alleviating chronic back pain or correcting asymmetries.

Dr Lim’s 2024 Breast Reduction Guide

What Is Breast Reduction Surgery?

Breast reduction surgery is a procedure that reduces the size and weight of large, heavy breasts. This surgery can help to alleviate a range of physical problems related to overly large breasts, including back and neck pain, skin irritation and posture problems.

The procedure involves removing excess breast tissue, fat, and skin to achieve a breast size in proportion with your body. In some instances, the areola may also be reduced and the nipple repositioned. It’s a significant surgery that usually involves general anaesthesia and a recovery period of several weeks.

While sometimes categorised as a cosmetic procedure, breast reduction surgery is a medically necessary procedure for some patients. When physical symptoms are severe and non-surgical treatments have not provided relief, breast reduction may be recommended. In such cases, Medicare cover might be applicable.

Criteria for Medicare Cover for Breast Reduction Surgery

Understanding the criteria for Medicare coverage for breast reduction surgery is essential. As stated earlier, Medicare covers certain procedures if they are considered medically necessary. So, what qualifies as ‘medically necessary’ for a breast reduction?

Medicare specifies certain conditions that must be met for the procedure to be considered for coverage. Firstly, you must suffer from chronic neck, shoulder, or back pain due to the weight of your breasts. You must have tried non-surgical treatments, such as physical therapy and pain medication, without success. Often, it is required that you have also sought advice from a physiotherapist or chiropractor.

Understanding Medicare Item Numbers

Now that you understand the criteria for Medicare coverage, let’s explore the concept of Medicare item numbers. An item number is a unique number assigned to each service that Medicare provides a benefit for. Each item number corresponds to a specific service, procedure, or test and has a set benefit amount that Medicare will pay.

Understanding these item numbers is crucial to understanding how much Medicare will cover for a particular procedure. It’s also important to note that multiple item numbers can be associated with a single procedure, depending on the complexity and specifics of the surgery.

Item Numbers for Breast Reduction Surgery

Breast reduction surgery has specific Medicare item numbers associated with it. The primary item number 45523, which covers bilateral breast reduction. This number applies when both breasts are reduced in size due to medical necessity. There is also item number for unilateral breast reduction 45520.

Knowing these specific item number is crucial as it determines whether Medicare will cover your breast reduction surgery and how much you can expect to be reimbursed for the procedure.

Here are the details of the Breast Reduction Medicare Item Numbers:

Medicare Item Number 45520

Reduction mammaplasty (unilateral) with surgical repositioning of nipple, in the context of breast cancer or developmental abnormality of the breast

Medicare Item Number 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 insertion of any prosthesis

How Does Medicare Cover Breast Reduction Surgery?

So, how exactly does Medicare cover breast reduction surgery? Once you meet the criteria and have the appropriate item numbers, Medicare will provide a benefit towards the cost of your surgery. This benefit is typically a percentage of the Medicare Benefits Schedule (MBS) fee for that service.

It’s important to note that Medicare does not cover the entire cost of the procedure. There can still be out-of-pocket costs, including surgeon’s fees, hospital fees, and anaesthetic fees. Therefore, it is crucial to discuss these potential costs with your plastic surgeon or medical team before the procedure.

Private Health Insurance to Cover for Breast Reduction Surgery

Private health insurance can potentially cover part of the cost of breast reduction surgery in Australia, but the extent of coverage depends on the specifics of your insurance policy.

Generally, private health insurance policies are split into hospital and extras cover. For breast reduction surgery, you would be looking at your hospital cover, which deals with costs associated with medical treatments in hospital.

But not all policies will automatically cover breast reduction surgery. It is typically covered under policies that include plastic and reconstructive surgery, but you’ll need to check with your insurer as it can depend on whether the procedure is considered medically necessary versus cosmetic.

If the surgery is deemed medically necessary (for example, to relieve back, neck, or shoulder pain, or prevent other health complications), and you have the appropriate level of cover, then your private health insurance could cover the following:

A portion of the hospital stay: This includes accommodation and nursing care while you’re in hospital
Theatre fees: The costs associated with using the operating theatre
Part of the medical costs: This could include the surgeon and anaesthetist fees

You also need to consider potential out-of-pocket costs, which can include the medical gap if your plastic surgeon charges more than the Medicare Benefit Schedule fee.

It is always best to contact your insurer directly to understand exactly what is covered by your policy, what the potential out-of-pocket costs may be, and whether any waiting periods apply. They can provide you with a detailed understanding of your coverage and any limitations.

Superannuation to Pay for Breast Reduction Surgery

In Australia, superannuation funds can be accessed early under specific circumstances, which are primarily to do with financial hardship or on compassionate grounds. However, using superannuation to pay for medical procedures, including breast reduction surgery, is not straightforward and should be carefully considered.

In terms of medical procedures, early release of your superannuation can be granted on compassionate grounds if the procedure is to treat a life-threatening illness or injury, to alleviate acute pain, or to alleviate an acute mental disturbance. The procedure must also not be readily available through the public health system.

While it’s possible that a case could be made for breast reduction surgery under the acute pain criterion, this is not guaranteed and would require substantiation from a medical practitioner. The Australian Taxation Office (ATO) handles applications for early release on compassionate grounds, and the decision would ultimately be at their discretion.

Furthermore, accessing your superannuation early should not be taken lightly as it can significantly impact your retirement savings. It is also not a solution for everyone, as you need to have enough money in your super to cover the costs.

It’s advisable to consider all options, such as Medicare, private health insurance, and personal savings, before deciding to access your superannuation early. Also, professional financial advice could be sought before making such a decision.

See Dr Lim’s Before and After Breast Reduction Photo Gallery

Breast Reduction Patient 22 — Front View

Click here to see more pictures.

Additional Resources for Understanding Medicare Cover

Understanding Medicare coverage for breast reduction surgery can be a complex process. Fortunately, there are many resources available to help you navigate this process.

The Australian Government’s Department of Health website provides detailed information about Medicare, including what services are covered, how benefits are calculated, and how to apply for coverage. The department’s Medicare Benefits Schedule online is another valuable resource, providing a comprehensive list of item numbers and their associated benefits.

Professional organizations like the Australian Society of Plastic Surgeons can also provide useful information and resources.

Understanding how Medicare covers breast reduction surgery in Australia requires understanding the specific criteria for coverage, the concept of Medicare item numbers, and the process to apply for coverage. With this information in hand, you can make informed decisions about your health care and navigate the process of obtaining Medicare coverage for your breast reduction surgery.

FAQs about Medicare and Breast Reduction Surgery

Q. Is breast reduction surgery covered by Medicare Australia?

Yes, Medicare Australia does cover a portion of the cost for breast reduction surgery, but certain criteria must be met. Generally, it’s covered when it’s deemed medically necessary rather than for cosmetic purposes. This could be in cases where a person is experiencing significant physical discomfort, such as back, neck, or shoulder pain, due to the size of their breasts. Always consult with your plastic surgeon to understand your coverage.

Q. How do I know if I’m eligible for Medicare coverage for my breast reduction surgery?

Eligibility for Medicare coverage for breast reduction surgery is determined by a doctor based on medical necessity. This means you must be experiencing significant discomfort or pain, skin irritations, difficulty with physical activities, or other related health issues due to the size of your breasts.

Q. What out-of-pocket costs should I expect for breast reduction surgery with Medicare?

While Medicare covers a portion of the costs associated with medically necessary breast reduction surgery, it does not cover everything. There may be out-of-pocket costs such as specialist consultation fees, anaesthesia fees, hospital costs, and potential costs for postoperative care or complications. The exact amount can vary greatly based on your specific case and the terms of any additional private health insurance you may have.

Q. Can I use private health insurance in conjunction with Medicare for breast reduction surgery?

Yes, if you have private health insurance, you can often use it to cover some of the costs not covered by Medicare, such as hospital accommodation or surgeon’s fees. The exact amount covered will depend on your specific policy and the terms and conditions of your private health insurance. Be sure to discuss this with your insurance provider to fully understand your coverage.