Will Medicare Cover Breast Lift (Mastopexy)?

Medicare Cover for Breast Lift/Mastopexy

When considering the question of whether Medicare will cover a breast lift in Australia, it’s important to understand the multifaceted nature of such decisions.

In this blog, Sydney Plastic Surgeon Dr Jake Lim will explore Medicare cover for breast lift, criteria for coverage and Medicare item numbers.

Download Dr Lim’s 2024 Breast Lift Surgery Guide

Medicare Coverage in Australia

When you’re considering medical procedures in Australia, understanding the scope and limits of Medicare is essential. Medicare, Australia’s public health insurance scheme, provides you with access to a range of healthcare services, often at no cost or at a lower cost. It’s designed to ensure that all Australian residents have access to affordable medical care. But when it comes to specific procedures, especially those that may be seen as elective, the situation can get somewhat complicated.

Overview of Medicare Services in Australia

It’s important for you to grasp the broad offerings of Medicare. This system covers various aspects of healthcare, including general practitioner consultations, specialist visits, tests and examinations, and a portion of the costs for prescription medicines. Medicare is known for its accessibility and commitment to public health, aiming to provide comprehensive care to all Australians. However, it’s essential to understand that not all medical procedures and treatments are covered under this scheme.

General Criteria for Procedure Coverage

To navigate this system effectively, you need to be aware of the general criteria that Medicare uses to determine coverage. Medicare covers treatments that are considered medically necessary. This means the procedure must be essential for the diagnosis, cure, mitigation, treatment, or prevention of disease or illness. The necessity is often determined by the urgency, the severity of your condition, and the clinical evidence supporting the treatment’s effectiveness.

Distinction between Elective and Medically Necessary Procedures

This brings us to a critical distinction: elective versus medically necessary procedures. An elective procedure is one that is planned in advance and is not essential for immediate health or survival. In contrast, a medically necessary procedure is one that is required to treat or diagnose a serious condition. Medicare coverage tends to lean more towards procedures that are deemed medically necessary.

For instance, in the case of a breast lift, Medicare will scrutinise whether the surgery is purely for cosmetic reasons or if it’s required to address significant physical discomfort or health issues. If the procedure is to correct abnormalities caused by illness, injury, congenital anomaly, or to improve the functioning of a malformed part of the body, there’s a higher likelihood of it falling under the umbrella of medical necessity.

In the context of a breast lift, it’s important to consult with your GP and plastic surgeon. They can offer guidance on whether your case might be considered medically necessary and thus eligible for Medicare coverage. They’ll also assist you in understanding the documentation and evidence required to support your claim. Keep in mind that every individual’s situation is unique, and professional medical advice is indispensable in these matters.

Criteria for Breast Lift Coverage

If you want to know whether Medicare will cover a breast lift in Australia, it’s important to first clarify what a breast lift entails and when it might be considered medically necessary. A breast lift, medically known as mastopexy, is a surgical procedure that reshapes and raises ptotic breasts. This is achieved by removing excess skin and tightening the surrounding tissue to reshape and support the new breast contour.

The medical necessity of a breast lift is not straightforward. Unlike procedures that are clearly for health conditions, such as a heart surgery, the necessity of a breast lift often falls into a grey area. It is generally considered medically necessary when the ptosis of breasts causes significant physical discomfort, skin conditions like dermatitis, or other health-related issues. It’s not just about appearance; it’s about how these physical changes impact your daily life and health.

Specific Conditions under Which Medicare Might Cover a Breast Lift

Medicare coverage for a breast lift is not a given. For Medicare to potentially cover this procedure, certain specific conditions typically need to be met. These might include:

Severe Breast Asymmetry: If one breast is significantly larger or shaped differently than the other to a degree that causes physical discomfort or functional problems
Post-Mastectomy Reconstruction: If you have undergone a mastectomy due to breast cancer or other serious conditions, reconstruction, which can include a breast lift, may be covered
Chronic Skin Conditions: Situations where excessive breast skin leads to chronic skin conditions, like intertrigo or dermatitis that do not respond to conventional treatment
Back or Neck Pain: If you experience severe back or neck pain attributable to the weight or position of your breasts, and this pain is not relieved by other treatments

Documentation and Medical Evidence Required for Coverage

To determine eligibility for a Medicare-covered breast lift, you’ll need to provide comprehensive documentation and medical evidence. This usually includes:

Medical History and Records: These should detail the physical symptoms you are experiencing, previous treatments you’ve tried, and their outcomes
Photographic Evidence: In medically necessary cases, visual documentation of your condition is required to demonstrate the severity of your breast sagging
Letters of Recommendation: Sometimes, letters from healthcare providers advocating for the necessity of the procedure can support your case

It’s important to remember that even with all the appropriate documentation, Medicare coverage is not guaranteed. If you’re considering a breast lift/Mastopexy and hoping for Medicare coverage, start by discussing it with your plastic surgeon. Dr Lim’s team can guide you through the process of gathering the necessary documentation and evidence, and help you understand the likelihood of your procedure being covered. Remember, navigating the healthcare system can be complex, but being well-informed and prepared can make a significant difference in your journey.

Medicare Item Numbers for Breast Lift Surgery

Understanding how Medicare in Australia covers breast lift surgery requires a close look at item numbers 45558 and 45556. These aren’t just arbitrary codes; they are essential for navigating the Medicare system and understanding your potential eligibility for coverage.

Item numbers 45558 and 45556 play an important role in the Medicare system. They are used to identify and categorise breast lift surgeries, serving as a reference point for both healthcare providers and patients. Each number corresponds to specific conditions and types of procedures, guiding the Medicare claims process:

Item Number 45558: This code is generally used for cases where breast lift surgery is required for both breasts. The need for surgery under this item number must be backed by medical reasons, not just cosmetic desires
Item Number 45556: This item number is typically applied to breast lift surgeries that involve only one breast, often in the context of breast cancer or developmental abnormalities

Private Health Insurance and Breast Lift Coverage

Private health insurance is an option for covering medical expenses not fully funded by Medicare. If you’re considering a breast lift, it’s important to review your private health insurance policy closely.

Check Your Policy: Policies vary significantly between providers and plans. Some may cover breast lifts, but this is often under specific conditions, similar to those of Medicare (e.g., for reconstructive purposes rather than cosmetic reasons)
Understanding the Limits: Be aware of the limitations and exclusions of your policy. Some policies may have caps on how much can be claimed or may exclude certain types of surgery altogether
Waiting Periods: If you have recently taken out a new policy or upgraded your coverage, you might need to serve a waiting period before you can claim for certain procedures

Out-of-Pocket Costs for a Breast Lift

If your breast lift is not covered by Medicare or private insurance, you will need to cover the costs yourself. These out-of-pocket expenses can be substantial, so it’s important to plan accordingly.

Surgeon’s Fees: The largest portion of the cost will be your surgeon’s fee. This can vary widely depending on your surgeon’s experience and the complexity of the surgery
Hospital and Anaesthetic Costs: The procedure is done in a hospital, so there will be additional costs for the hospital stay and anaesthesia. These can also vary greatly
Post-operative Care: Factor in the cost of any post-operative care, including follow-up appointments, medications, and any necessary support garments

FAQs about Medicare and Breast Lift

Is it possible to get a breast lift covered under mental health grounds if it’s causing psychological distress?

In some cases, if a breast condition is causing significant psychological distress, coverage might be possible under mental health grounds. This would require a psychological assessment and detailed documentation from mental health professionals supporting the claim.

What should I consider when choosing a surgeon for a breast lift, particularly in the context of insurance and Medicare coverage?

Choosing the right surgeon for a breast lift is a critical decision. It’s important to consider not only their experience and qualifications but also their familiarity with insurance and Medicare processes in Australia. A surgeon who is well-versed in these areas can provide valuable guidance on funding options and the likelihood of obtaining coverage for your procedure.

Medical References about Breast Lift

Mastopexy (Breast Lift Surgery) – WebMD
Breast Lift – Australian Society of Plastic Surgeon
Mastopexy (breast lift) – NHS
Breast Lift – Mayo Clinic
Breast Lift (Mastopexy): Surgery & Recovery – Cleveland Clinic