Will Medicare and My Private Health Insurance Cover My Breast Reduction Surgery?
If you’re contemplating a breast reduction (Reduction Mammoplasty) chances are you want to know if your Private Health Insurance and/or Medicare will cover any or all of your surgery costs.
Breast Reduction Surgery (Reduction Mammoplasty) – Download Dr Briggs FREE Guide
Medicare rules and regulations are very strict when it comes to any form of Breast surgery. Many forms of breast surgery are not eligible for a rebate as they are purely cosmetic. However, Breast Reduction Surgery is one of the exceptions (in specific situations) and are currently on the Medicare Benefits Schedule.
This means that your Private Health Insurance will cover some of your hospital costs. While Medicare will make a small contribution to the medical costs associated with the private Surgeon and Anesthetist.
There are often numerous health concerns that relate to a patient’s reasons for wanting Breast Reduction Surgery, including;
- Relief from chronic skin infections under the breasts (‘intertrigo’)
- Relief from back, neck and shoulder pain caused by the heavy breasts
- Or, to remedy other breast health conditions that affect the quality of living.
Will Medicare Cover My Breast Reduction?
Having heavy breasts can cause chronic health conditions. These health conditions are a legitimate medical reason for having breast reduction surgery.
A referral from your General Practitioner (GP) documenting; the pain and suffering your breasts cause you on a daily basis and any previous treatments you have undergone to alleviate the discomfort are proof of the chronic conditions your breasts cause.
Why Should I Consider A Breast Reduction?
Breast Reduction surgery, also known as reduction mammoplasty, can prevent or treat recurring problems related to heavy breasts. Some of the key reasons for breast reduction surgery include:
- Relief from Physical Discomfort: Breast reduction surgery can alleviate chronic physical discomfort associated with large and heavy breasts. This includes relief from neck, shoulder, and back pain caused by the excess weight of the breasts.
- Changed Posture: Large breasts can lead to poor posture, which can result in musculoskeletal problems. Breast reduction surgery can help posture by reducing the strain on the back and shoulders.
- Reduction in Skin Irritation: Large breasts can cause skin irritation, rashes, and chafing, particularly in the areas beneath the breasts. Breast reduction surgery eliminates or reduces this problem.
- Physical Activity: After breast reduction, many individuals may find it easier to engage in physical activities and exercise, which can lead to a healthier lifestyle.
- Customised Results: Surgeons work with patients to get their wanted breast size and shape, tailoring the procedure to meet individual goals and preferences.
It’s important to note that breast reduction surgery is a highly individualised procedure, and the specific reasons can vary depending on a person’s unique circumstances and goals. Patients considering breast reduction should consult with a board-certified plastic surgeon to discuss their options, expectations, and potential reasons in greater detail. To be eligible to claim your surgery on Medicare, you will need a Medical Referral from your General Practitioner. You can obtain this before your initial consult with Dr Briggs or after your initial consult but before your pre-operative appointment.
Why Is the Medicare Rebate Question for Breast Surgery So Confusing?
The answer to this question can be confusing for most patients seeking cosmetic surgery. It will vary depending on the patient and the procedure required. Medicare will sometimes offer a minor rebate on some procedures. However, rebates are generally available only for reconstructive plastic surgery or what is deemed ‘essential’ medically necessary surgery.
Most breast procedures do not fall under this category as they are seen to be medically unnecessary. But Breast Lift and Breast Reduction surgery may fall under this category for some patients.
The Medicare rebate guidelines are very clear when it comes to Plastic & Cosmetic Surgery; Medicare will not cover ‘non-therapeutic cosmetic surgery’ NOR ‘non-therapeutic plastic surgery’ procedures.
Significant Breast Ptosis after pregnancy and chronic back pain or skin Infections related to large breasts are chronic medical conditions and may lead to eligibility for a minor rebate. In other words, you will get some financial assistance but you will still have out of pocket costs.
Breast Reduction Surgery and Medical Benefits Schedule (MBS)
If you have the required documentation for your Breast Reduction Surgery and you meet the current Medicare criteria, then yes, you may qualify for a rebate from Medicare for your procedure. MBS changes at the end of 2018 included; additional photographic proof, examination evidence/reporting documentation and stricter patient criteria for Medicare rebates for Breast Reduction Surgery. Similarly, this also had an impact on other procedures relating to women’s health.
Your eligibility may depend on the following Medicare criteria;
(a) for patients with macromastia (large breasts) and experiencing pain in the neck or shoulder region; and
(b) not with insertion of any prosthesis – this means you cannot have an implant put in when having the reduction to be able to claim the rebate
In addition, to the above, you may be eligible for rebates on your surgery and hospital cover from your Private Health Insurance provider. This will, however, only apply if; your condition meets the criteria for a Medicare Item Number and you have adequate coverage for the procedure.
Bronze Hospital cover is enough for Most Breast Reductions. However, there are instances where Silver hospital cover may be necessary. You should always check directly with your Health Fund regarding your policy and whether you are eligible for cover for the Medicare item number.
It’s important to recognise that Medicare items and rebate eligibility criteria for Breast Reduction Surgery are subject to change, with very little notice or forewarning. Therefore, you should discuss your eligibility with Dr Briggs and his team as they will have the most up-to-date information on hand.
Medical and Health Reasons That Cause Patients To Seek Breast Reduction Surgery
- Chronic skin infections.
- Excess perspiration around and/or under breasts.
- Challenges when exercising caused by large, pendulous breasts.
- Back pain, neck pain or shoulder pain related to breast weight, breast volume or breast ptosis.
- As well as, other breast-weight related health conditions that impact your health and quality of life.
If you are chronically suffering from one or more of the above symptoms due to your breast weight or volume, your Breast Reduction surgery may be eligible for a rebate. However, it will always depend on if you meet the criteria as to whether you are eligible or not.
If I Am Not Eligible for A Medicare Rebate, Will My Private Health Fund Cover My Breast Procedure?
Private Health Funds only ever cover a breast reduction procedure if;
- It has an MBS item number
- The patient meets current Medicare eligibility criteria
- And a Medicare Statement of Claim and Benefit has been processed.
Therefore, you must meet the criteria for a Medicare rebate to seek coverage from your Health Fund. A general rule is if Medicare will not pay, private health will not pay.
If Medicare or a Health Fund do not cover my breast reduction, how much will my procedure cost?
The cost of undergoing a Breast Reduction with a Plastic Surgeon in Melbourne will vary. This is because every procedure is unique and specific so as to meet your; anatomy, specific needs and wanted surgical outcome.
Not only can Dr Briggs and his team help you with assessing your eligibility for coverage by MBS or your health fund, but they can also help you understand the cost and risks of surgery.
To access your eligibility to claim a Medicare rebate for your Breast Reduction Surgery, visit your General Practitioner or other Medical specialist and ask for a referral to Dr Briggs.
Alternatively, you can also speak to our knowledgeable reception team, who are available to answer your questions. Simply phone us on 1300 264811.
So Will Medicare Cover My Breast Reduction Plastic Surgery?
YES – Medicare Rebates may apply for Breast Reduction / Reduction Mammoplasty – but strict criteria must be met. There is no guarantee until Dr Briggs examines you, but ask your General Practitioner (GP) for information to see if you qualify and get a refferal before booking your consultation with Specialist Plastic Surgeon Dr Briggs.
Dr Patrick Briggs Melbourne
Dr Patrick Briggs FRACS (Fellow of the Royal Australasian College of Surgeons) is a Specialist Plastic and Cosmetic Surgeon.
Both he and his team are dedicated to patient care and are committed to treating each and every patient with respect and privacy.
Want more information about your Procedure?
What to Bring to Your Consultation
- If you like, please bring a friend or relative to help discuss the information and your choices.
- Take a lot of notes and thoroughly examine the documents your surgeon provides.
- You may need to undress so it’s a good idea to wear simple clothes.
The information provided in this article is for educational and informational proposes. It is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this article. The author and publisher of this article make no representation or warranties with respect to the accuracy, applicability, or completeness of the content of this article. The information contained in this article is strictly at your own risk.