Will Medicare Cover Breast Reduction Surgery?

Will Medicare and My Private Health Insurance Cover My Breast Reduction Surgery?

If you’re contemplating a breast reduction chances are you want to know if your Private Health Insurance and/or Medicare will cover any or all of your surgery costs.

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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. However, Breast Reduction Surgery is one of the exceptional procedures that are currently on the Medicare Benefits Schedule.

This means that your Private Health Insurance will cover some or all of your hospital costs. While Medicare will make a small contribution to the medical costs associated with the private Surgeon and Anaesthetist.

In some cases, patients may even use their Superannuation to fund their surgery by applying for an early release of funds on compassionate grounds for medical treatment.  You may be wondering Why is that the case?

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, for example going to the gym, and jogging.
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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 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.

With the information from your GP and a physical examination, Dr Briggs will be able to determine your eligibility for the Medicare Item number.

The criteria for a Medicare Claim for Breast Reduction Surgery is as follows;

(a) for patients with macromastia (large breasts) and experiencing pain in the neck or shoulder region; and

(b) not with the insertion of any prosthesis – this means you cannot have an implant put in when having the reduction to be able to claim the rebate.

Why Should I Consider A Breast Reduction?

Breast Reduction surgery can be a life-changing procedure for patients. It can prevent or treat recurring problems related to heavy breasts giving patients overall better quality of life.

Most breast reduction patients are happy to find they have a new lease on life. This ranges from better sleep to participating in new activities, e.g. fitness classes that they have been unable to attend in the past. Not to mention an improvement in both self-confidence and self-esteem.

Further benefits from Breast Reduction surgery include; being able to wear fashionable bras, swimwear and other items of clothing you formerly felt weren’t suited or too uncomfortable for your fuller breasts.

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.

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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 qualify under this category and 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 in an instant, 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.

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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.
  • In fact, difficulty purchasing bras and other items of clothing can also be on the list.

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 cover 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 desired 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 GP or other 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.

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Can I Use My Super Fund for Breast Reduction Surgery?

Some patients may consider requesting an early release of superannuation funds to help pay for Breast Reduction surgery, however, before doing so, it is important to note that:

  • Each application for early Super release is assessed on an individual basis.
  • Tax implications apply so seek professional financial advice.
  • Superfund withdrawal applications can be made through your MYGOV account via the Australian Tax Office (ATO).
  • Once they receive your application the ATO makes decisions about early-super-release applications within approximately 14 days.

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 or book your consultation with Specialist Plastic Surgeon Dr Briggs after getting a referral from your GP.

Dr Patrick Briggs Specialist Plastic Surgeon

Dr Patrick Briggs Melbourne Plastic Surgeon – FRCS (Plas)

Specialist Plastic and Cosmetic Surgery Clinic in Melbourne

Dr Patrick Briggs is a Specialist Plastic and Cosmetic Surgeon. Both he and his team are dedicated to excellence in patient care and are committed to treating each and every patient with respect and privacy.

Not only does he offer high-quality results he also offers natural-looking plastic and cosmetic surgery results. Furthermore, he is experienced in Breast, Body and Face Surgery having performed over 4500 Surgeries in private practice. 

Dr Patrick Briggs is an expert in breast, face and body surgery for men and women.

How can we help?

Dr Briggs’ Patient Coordinators take pleasure in assisting you with any questions when considering a plastic surgery procedure. Please call the Hawthorn East clinic in Melbourne between 8 am – 6 pm on Weekdays.

Phone 1300 264 811Email us or Book a free 15-minute Call with Dr Patrick Briggs’s team.

What Next?

Want more information about your Procedure?

  • For more information about pricing and payment methods, please visit our page on Surgery Payment options.
  • Talk to our Patient Care Team from 8am to 6pm Monday to Friday on 1300 264 811.
Dr Patrick Briggs consultation

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.

How to Book a Consultation

  • Dr Briggs’ Consultation fee is $300.
  • A referral from your GP or your specialist is helpful but not essential. However,
  • To claim any Medicare or Health Insurance you will need a referral.
  • Please contact the Patient Care Team at Coco Ruby Plastic Surgery today to book your consultation.