Will Medicare Pay For My Breast Reduction

If you’re considering a breast reduction to reduce the size and weight of your breasts, it may be a good idea to learn about breast reduction Medicare cover. In some cases, Medicare can help towards some of the costs of your procedure. However, specific criteria will need to be met to be eligible.

Understanding how Medicare applies to breast reduction surgery can be confusing, especially with different item numbers, potential out-of-pocket costs, and the possible ways that private health insurance could also help, if you are covered.

In this blog, we’ll go through what you need to know about breast reduction Medicare cover and what makes a candidate eligible. We’ll also discuss the total costs of breast reduction and how they are calculated.

When can breast reduction Medicare cover be granted?

Medicare provides benefits for medical procedures that are deemed necessary, rather than elective. For breast reduction surgery, this means that the procedure must be performed for medical reasons, such as chronic pain, rather than purely for cosmetic (aesthetic) purposes.

Medicare assigns item numbers to procedures that meet specific medical criteria. The relevant item number for breast reduction surgery is 45523, which covers “reduction mammaplasty with surgical repositioning of the nipple” when it is performed to relieve significant symptoms. However, simply experiencing discomfort won’t necessarily be enough to qualify under this item number.

To be eligible, you’ll typically need to demonstrate that you have ongoing physical issues related to large breasts, such as back, neck, and shoulder pain, chronic skin irritation, or recurrent infections under the breast fold. Your surgeon may also need to provide supporting documentation, including evidence that other treatments, such as physiotherapy or supportive garments, have not been effective in relieving your symptoms.

If your procedure qualifies for the item number, Medicare will contribute to the cost, but it won’t cover everything. There will still be out-of-pocket expenses, and the total amount will depend on whether you have private health insurance and the total fees charged by your surgeon and hospital.

Out-of-pocket costs and private health insurance

Even if your breast reduction procedure can be partially covered by Medicare, there are still costs that you’ll need to pay. As a specific example, Medicare will cover a portion of the surgeon’s fee, but it’s unlikely to cover the entire amount.

There are also hospital and anaesthesia fees to consider. If you don’t have private health insurance, you may need to go through the public hospital system, or you may have to cover the full cost of a private hospital stay yourself.

If you do have private health insurance, your policy may cover some of the hospital costs, but this depends on your level of cover. It’s always best to check with your insurer to understand exactly what is covered and whether an excess fee applies.

To feel prepared for out-of-pocket costs, you’ll receive a personalised quote detailing the total costs of your procedure during your consultation process, as well as the exact number of costs that Medicare will cover, should you be eligible. We also recommend discussing costs with your private health insurance provider as early as possible to make sure that you’re fully prepared ahead of time and will know what to expect.

Seeing your GP, specialist or surgeon and getting approval

The first step in determining whether you qualify for breast reduction Medicare cover is to consult with your GP or a specialist.

During your consultation, they will assess your symptoms, medical history, and physical condition to determine whether your case meets the Medicare criteria.

If your symptoms are significant enough to qualify under the MBS item number, they may then provide the necessary documentation to support your case. This may include medical reports, imaging, or evidence of previous treatments you’ve tried. Once you have this information, you can check with Medicare and your private health insurer to confirm cover and any associated costs.

Then, a consultation with an experienced surgeon will give you the chance to discuss your symptoms, get a clear understanding of the costs involved, and further discuss the Medicare criteria. Since every case is different, speaking with a surgeon is the best way to get accurate, personalised information.

How overall breast reduction costs are calculated

The total cost of a breast reduction will depend on several factors, including the specific surgeon’s fees, hospital costs, anaesthesia fees and more.

Surgeon’s fees will vary depending on their qualifications and experience, as well as the complexity of the procedure. Anaesthesia fees will also depend on the anaesthetist’s qualification level and experience. Both of these fees will also need to consider factors like total procedure time, which can of course differ from one patient to another.

Hospital fees will depend on the specific hospital, but will typically need to cover operating theatre costs and any post-operative care provided by the hospital. Private health insurance may cover the hospital costs in some cases.

Overall, your breast reduction costs need to be calculated after finalising a treatment plan for your own individual needs and, therefore will require you to have a consultation to accurately calculate.

Book a consultation with Specialist Plastic Surgeon Dr Grant Fraser-Kirk

On the Sunshine Coast, Specialist Plastic Surgeon Dr Fraser-Kirk offers surgical procedures focused on different areas of the body, including the breasts.

Dr Grant Fraser-Kirk approaches each case with a supportive nature, ensuring that the chosen procedures are highly tailored to every patient’s unique needs and expectations.

As a Plastic and Reconstructive Surgeon, a high level of precision and skill is required to perform procedures effectively, that can only be gained after years of the right training and experience.

When you have your consultation located on the Sunshine Coast, you’ll be able to discuss your reasons for undergoing a breast reduction procedure, what kind of results you hope to achieve and whether or not your case would make you qualify for a Medicare rebate.

Please contact our team to organise your consultation with Dr Fraser-Kirk or to ask any further questions you may have.