Will Medicare Cover My Breast Reduction Procedure? Eligibility Criteria for a Medicare Rebate
What is a Breast Reduction Procedure?
A breast reduction procedure is a plastic and cosmetic surgery procedure that is performed to reduce the size of breasts. Also known as reduction mammoplasty, the procedure removes excess fat, glandular tissue, and skin from the breast. The procedure may also include nipple and areola repositioning to make them more central in appearance. If deemed medically necessary, Medicare may contribute a portion of the cost of your breast reduction procedure. As large breasts can cause pain and discomfort, there are many medical benefits of breast reduction surgery.
A breast reduction is a great choice for you if you have large and heavy breasts which cause you back pain or affect your self-confidence. You may be a candidate for this surgery if you are a nonsmoker and physically healthy with realistic expectations about what the procedure can achieve.
Since a reduction mammoplasty is a surgical procedure, there are certain risks and complications, like every other surgical procedure, that may arise during or after the procedure that you need to discuss with your plastic surgeon in detail before making a decision.
Recovery from a breast reduction procedure is a long process and can take up to four to six weeks. You may experience swelling and bruising early on during the recovery period, however, it will resolve on its own, and eventually, the results of the surgery will become visible.
Will Medicare cover my Breast Reduction Procedure?
Medicare is a national health insurance scheme that subsidises medical procedures to provide affordable healthcare to citizens and residents. However, Medicare only contributes a portion of the cost of surgical procedures that are medically necessary and not those which are performed for aesthetic or cosmetic purposes.
Since breast reduction is usually done for cosmetic purposes, it’s not always covered by Medicare. If the breast reduction procedure is medically necessary and you can provide evidence of its necessity, then medicare may help to fund your breast reduction surgery. The provided evidence must be in the form of documentation claiming that your daily life is being affected by the size of your breasts. Your surgeon must also sign this document for you to be considered for a partially Medicare-funded breast reduction procedure.
It’s important to note that if the procedure is not medically necessary and your surgeon still goes on to sign and say that it is, the surgeon is then committing insurance fraud and that is a punishable offence.
Eligibility Criteria for a Medicare Funded Breast Reduction Procedure
For Medicare to cover your breast reduction procedure, it must be a medically necessary procedure and the symptoms must persist for at least six months before the procedure. Some of the conditions that make a breast reduction procedure medically necessary are mentioned below:
Persistent Back Pain
Large breasts can put extra pressure on your back and result in chronic back pain that may be relieved temporarily with pain relievers. However, this pain will persist unless the pressure is removed which can be done with a reduction mammoplasty procedure. In this case, Medicare is likely to cover your Breast reduction procedure.
Restriction of daily physical activities
Large breasts and the pressure they put on the shoulders and the back can restrict you from many daily activities as doing any activity, strenuous or not, may cause pangs of pain. Along with that, it will worsen the already present chronic back pain. If you have to think of the back pain or the weight of your breasts before doing any physical activity, then you may be eligible for a partially Medicare-funded breast reduction procedure.
Large breasts are heavy and due to gravity, they can sag quite a bit. This sagging creates a crevice or folds between the breast and skin covering the ribs. Also, larger breasts often mean under-breast sweating that can result in moisture being trapped in this crevice. This can result in the growth of microorganisms which consequently causes skin infections and rashes that can be quite painful and hard to treat.
If the skin infections persist or become a recurring problem, then you may be eligible for breast reduction surgery which is partly contributed to by Medicare. However, it’s important to keep in mind that for Medicare to fund your reduction mammoplasty procedure, especially in this case, you must have tried non-surgical interventions first with little to no results. Only then, you can apply for the medicare rebate.
Chronic back pain and the pressure on your shoulders due to large breasts can be relieved by using supporting garments. Moreover, to be able to do any physical activity with large breasts, you may need to wear sturdy bras that keep your breasts in place.
All of these garments are often used to treat the side-effects of having large breasts but they themselves can result in skin irritation and annoy you throughout the day. Wearing a bra, for example, can result in a pressure line over your shoulder where the bra strap usually is due to the mere weight of your large breasts.
More on Claiming a Medicare Rebate
If you suffer from these medical issues and non-surgical options are not yielding any results for you, then you may be eligible for a Medicare rebate. Another important criterion is that these issues must persist for at least six months with no improvement, even with treatment.
An important point to keep in mind here is that your entire procedure will not be covered by Medicare. You will have some out of pocket expenses that you need to figure out beforehand.
Another important thing to keep in mind is that you won’t receive pre-authorisation from Medicare meaning that Medicare won’t pay for the procedure beforehand. You will be reimbursed for the procedure by Medicare instead. Also, you may be hospitalized and those costs are usually not covered by Medicare.
This is why it is best to have all of the evidence ready to prove that this procedure was in fact medically necessary or else you will end up having to pay more than expected.
You can ensure authorisation from Medicare by gathering documentation from your doctor, physical therapist, chiropractor, and so on claiming that none of the non-surgical interventions have relieved your pain and that it is medically necessary for you to undergo this procedure.
What Medicare Item Numbers Cover a Breast Reduction Procedure
45520: Reduction mammaplasty (unilateral) with surgical repositioning of the nipple, in the context of breast cancer or developmental abnormality of the breast (Anaes.) (Assist.)
45522: Reduction mammaplasty (unilateral) without surgical repositioning of the nipple: (a) excluding the treatment of gynecomastia; and (b) not with the insertion of any prosthesis (Anaes.) (Assist.)
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 the insertion of any prosthesis (Anaes.) (Assist.)
Requirements for these MBS Item Numbers
For you to be eligible for Medicare Rebate using the Item numbers; 45520, 45522, 45523, you must meet the following requirements:
- The symptoms like the neck, shoulder, and back pain must persist for more than six months
- Traditional, non-surgical approaches must have yielded minimal to no results
- The symptoms must affect your day to day life and hinder you from doing normal activities.
- The procedure should not include the insertion of a prosthesis, that is you cannot have a reduction mammoplasty with implant placement under Medicare rules.
If you meet these requirements, you can easily apply for a Medicare Rebate for your medically necessary reduction mammoplasty procedure.
What to Expect when applying for Medicare Rebate
When applying for a Medicare rebate, be prepared to spend hours on the phone. This is completely normal. You will also need to provide evidence in the form of documentation that is signed by your doctor, physical therapist and chiropractor. When it comes to these documents, more is better than less.
To be eligible for the Medicare rebate, you need to meet a strict set of criteria and if you fail to meet even one of the criteria, Medicare will not fund your procedure. You need to keep this in mind and make sure that you meet all criteria, with proof, before making any decision to undergo the procedure.
You also need to be prepared to pay for a portion of the charges as Medicare doesn’t completely fund the procedure but rather subsidises it. And if there are any outpatient costs, you may need to pay those yourself, as well.
Associated Procedures that are covered by Medicare
Medicare covers all cosmetic surgery and plastic surgery procedures that are deemed medically necessary. If you need to undergo any procedure that is usually considered a cosmetic procedure but you can provide proof that it is interfering with your daily life and affecting your quality of life, then it can be deemed medically necessary and Medicare is likely to cover it.
There are many cosmetic procedures of the breast that may be funded by Medicare and have their own MBS Item numbers. These include:
- 45554 – Removal and replacement of the breast implant with more than 50 per cent of the capsule removed
- 45553 – Removal and replacement of breast implant
- 45051 – Breast Cancer reconstruction
- 45060 – Breast Asymm incl mastopexy or implants of different volumes
- 45061 – Breast Asymmetry stage 1
- 45062 – Breast Asymmetry stage 2
- 45528 – Breast reconstruction
- 45556 – Unilateral Mastopexy for Breast Ptosis
- 45558 – Bilateral Mastopexy for Breast Ptosis
- 45060/45061/45062 – Breast Asymm
- 45551 – Removal only of breast implant and half capsule
- 45524 – Mammaplasty Augmentation performed after cancer or abnormality
- 31506 – Breast surgery due to abnormality detected by mammography
- 31500,31503 – Breast Surgery due to benign lesion
- 31566 – Breast surgery with nipple repositioning, excision.
- 45559 – Tuberous, tubular or constricted, correction of breast
You can look up your MBS item number and check if any of the procedures you wish to undergo might be funded by Medicare or not.
What experience does Dr Doyle have in breast reduction surgery?
Dr Doyle is an Australian Specialist Plastic Surgeon (FRACS), which means he has obtained the highest qualifications for plastic surgery in Australia. With a special interest in breast surgery, Dr Mark has learnt specialised techniques to not only reduce the size of the breast but to reshape them into a natural, proportionate and aesthetically pleasing shape.
Frequently Asked Questions
Will I need to stay in the hospital after my surgery?
Breast Reduction surgery is a major surgery that is performed by Specialist Plastic Surgeon, Dr Mark Doyle in John Flynn Hospital nearby the Coolangatta airport. You may either be discharged the same day or in a couple of days after the surgery, depending on multiple factors.
There is a possibility that you will be required to spend a night or two in the hospital. This is so that you can be observed as you may be experiencing nausea and pain.
Either way, you will be informed beforehand so that you can make the necessary preparations.
How long is the surgery?
Breast reduction surgery is a plastic surgery procedure that can take anywhere between 2 hours to 3 hours.
What if I am not happy with the surgery?
If you are not happy with the results of your surgery, you need to speak to your surgeon. However, it is important for you to know that results of the surgery may not become visible until approximately six weeks after the surgery.
There will be a significant amount of swelling hiding the results at this time and you shouldn’t consider this to be the results of your surgery.
If even after the recovery period, you are not happy with the results, you may undergo surgeries or liposuction to fix asymmetry or similar problems. But they most probably won’t be funded by Medicare.
Is the surgery painful?
A breast reduction procedure is not painful and you will be put to sleep with general anesthesia for the procedure. However, the recovery phase may be marked by significant pain and discomfort which can easily be treated with pain relievers.
In fact, your doctor will prescribe you pain management medications to alleviate the pain and make your journey towards recovery easier.
Can I get implants placed during the procedure?
You can get implants placed during a breast reduction surgery, along with nipple repositioning and shaping your areolas. But this then disqualifies you from receiving a Medicare rebate for your breast reduction procedure.
- Upper Back, Neck Or Shoulder Pain? Solutions for Large and Heavy Breasts
- Nipple Reshaping and Areola Reduction: Who Is the Ideal Candidate, Benefits, and More
- Natural vs. Fake Boobs: 5 Ways to Get Natural-Looking Breasts
- Combining Plastic Surgeries: When Can Multiple Procedures Be Combined?
About Dr Mark Doyle FRACS (Plast) – Queensland Plastic Surgeon
Servicing patients in Gold Coast, Brisbane, Sunshine Coast, Cairns and New South Wales NSW – Northern Rivers, Byron Bay, Ballina, Lismore and more.
Dr Mark Doyle is a Specialist Plastic Surgeon with over thirty years of experience performing Breast, Body, Face and Nose surgery. As a highly esteemed plastic surgeon, Dr Mark is driven by an intense passion for helping patients achieve a happier, more beautiful self through advanced cosmetic surgery procedures.
He maintains a strong commitment to achieving the best possible results for all his breast, body, face and nose patients, both men and women.