Does Medicare Pay for my Breast Reduction Surgery?

Medicare for Breast Reduction Surgery Featured Image - Medicare Form

Can Medicare Cover Breast Reduction Surgery in Sydney?

Breast reduction is one of the most popular cosmetic procedures performed nowadays. Patients undergo breast reduction surgery due to various reasons: to achieve a more proportionate body, to get rid of back, neck, and shoulder pain or to get rid of skin chafing. If you are considering the procedure and hoping to get Medicare coverage, it is important to know that Medicare will pay for the procedure if you are getting the surgery due to an underlying medical condition. If you are only getting it done to enhance your physical appearance, Medicare will not cover the costs for it.

Medicare covers breast reduction surgery when it is done out of a medical necessity. Medicare will not pay for the procedure if you are getting it done for cosmetic reasons only. You can get coverage through Medicare if you get a relevant MBS code.

Dr Jeremy Hunt is a specialist plastic surgeon who performs breast procedures in Sydney and Wollongong NSW. His techniques aim to bring out the best possible results and improve your recovery after breast reduction surgery.

Will Medicare Pay for my Breast Reduction Surgery?

The answer to this question depends on your reasons for getting the surgery. People get the procedure done for all different kinds of reasons including:

To improve the symmetry of your breasts in case one of your boobs is larger than the others
To minimise the pain that is caused by having an overly large chest
To improve your physical appearance and your self-esteem
To acquire a more balanced figure

The list can go on for pages. However, Medicare will only cover the procedure if it is deemed a medical necessity. If your surgery is purely cosmetic in nature, Medicare will not pay for it, and you will have to pay for it out of your own pocket.

If having large breasts is creating problems related to body image and mental health, talking to a licensed therapist might help. Medicare does cover mental health services and you can get counselling appointments covered. It is the best way to address mental health problems caused by a certain body image.

Qualifying for Medicare Coverage

If you meet the criteria set by Medicare, you will get your breast reduction covered. All you have to do is to provide the required referrals and documentation to Medicare that indicates that you are having the surgery done due to medical reasons.

If you are getting it post-mastectomy, the process is very straightforward. On the other hand, if you are getting it done to get rid of the pain, you will need a doctor to verify that:

Breast reduction is essential to treat your pain
Any non-surgical procedures haven’t worked for you in the past
Your symptoms have lasted for a minimum of six months

It is important to remember that there are certain instances when pain is caused by a specific condition known as hypertrophy. This results in increased weight and density of your breasts, leading to pain and a variety of other problems. Medicare also covers hypertrophy as long as your doctor indicates that it is the cause of pain and other problems.

Choose a facility that accepts Medicare in order to receive complete benefits. You can look for the providers on Medicare’s official website as well. If you have a Medicare Advantage plan, make sure that the surgeon and facility are within the network. Choose a surgeon who is within your plan’s network. You can ask your surgeon directly whether they accept your plan or not.

What is Not Covered by Medicare?

Medicare will not cover elective cosmetic procedures under any circumstances. If you are getting the surgery done due to cosmetic reasons, you will have to cover 100% of the costs by yourself. This is true regardless of the type of Medicare plan.

Out-of-Pocket Costs for Covered Procedures

The amount you will have to pay out of your own pocket essentially depends on the Medicare plan and the facility where you decide to get the surgery done. It is important to note that you will get coverage regardless of the type of plan you have if your procedure is medically necessary. You can access your private health insurance provider to cover these costs for you. If your case is approved by Medicare, insurance will most likely pay for the surgery as well.

MBS Codes for Breast Reduction Surgery

These MBS Codes may be applicable for Breast Reduction Surgery:

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 insertion of any prosthesis
45520 Reduction of mammaplasty (unilateral) with surgical repositioning of the nipple, in the context of breast cancer or developmental abnormality of the breast
45522 Reduction mammaplasty (unilateral) without surgical repositioning of the nipple:
- (a) excluding the treatment of gynecomastia; and
- (b) not with insertion of any prosthesis

Expectations from Breast Reduction Surgery

First things first, it is important to keep your expectations realistic. Dr Hunt will guide you regarding the prep process for the surgery as per your unique needs.

Prior to the Breast Reduction Surgery

Dr Hunt will ask you to take a few different tests. Some of them include a routine breast exam, a mammogram, and other lab work. These tests will allow him to determine whether you are the right candidate for this surgical procedure or not. These tests also ensure that you are healthy enough to undergo the surgery. You will be asked questions about your medical history as well as your family’s medical history. Try to answer these questions as accurately and correctly as possible. Once Dr Hunt gives you a go, follow these steps to prepare for the surgery:

Do not take OTC drugs and supplements for at least two weeks before the surgery
Stop smoking for at least a month before getting the surgery
Avoid alcohol for at least two weeks before the procedure
Arrange for someone to drive you home after the surgery
Avoid consuming any food and drinks for at least 12 hours before the surgery
Get all the lab tests done in advance
Follow all the instructions given by Dr Hunt

During Breast Reduction Surgery

The process of breast reduction surgery involves the removing some of the fat, skin and glandular tissue to get the desired outcome. Your procedure might be done on an inpatient or outpatient basis. General anaesthesia is preferred for the breast reduction surgery.

The technique used to alter the size of your breasts will vary. It might include surgery via incisions, or liposuction to remove excess fat in your breasts.

Typically, Dr Hunt will create an incision around the areola that runs down each breast. Then, the excess tissue, fat, and skin will be removed to minimise the size of each breast. Dr Hunt will move on to reshaping your breast along with the repositioning of the nipple and areola. Repositioning is not always needed. In some cases, the nipple and areola are removed and reattached to a higher position (This is typically the case for overly large breasts). Dr Hunt might also minimise the size of the areola.

Recovery after Breast Reduction Surgery

Immediately after the surgery, your breasts will be covered with bandages. In some cases, drainage tubes will be attached to your breasts that are meant to drain fluids and minimise swelling. The recovery period will last for a few weeks. After that, you will be required to wear a surgical bra for a couple of weeks. Expect to take at least two weeks off from work. Because it will give you the due time to rest and recover. It is very normal to experience pain and tiredness after the surgery which makes doing day-to-day activities super hard.

You will be given painkillers and antibiotics to tackle pain and prevent any infections. Stay clear of blood thinning medications, smoking and alcohol as they can worsen bruising, and swelling, and prolong the recovery phase. You might not be able to notice an immediate difference in your breasts because your breasts will be still quite swollen. However, don’t freak out as it will settle down and you are going to see the results.

Long-Term Outcome of the Breast Reduction Surgery

Most patients start to feel like themselves once the recovery process is over. Most of the pain will be gone at this point. You might take some time to adjust to your new look. It is common to feel a little anxious or in some cases, overly excited. Get excited, as it is the time to go shopping for your new body. You will have scarring after the surgery. Dr Hunt will try to conceal these scars as effectively as possible. They will gradually fade over the years. If they still bother you, you can discuss scar removal options with Dr Hunt. Although, you will have to wait till you are fully recover.

Health Insurance and Breast Reduction Surgery

In order for your health insurance to cover the cost of the surgery, you need to get approval from Medicare. Make sure to be fully aware of the Medicare codes and rebate eligibility as these will essentially change/alter your claim. If your condition meets the criteria for Medicare Item Number, your insurance will most likely cover the charges. However, be sure to check with your individual health insurance provider.

Typically for breast reduction surgeries, a Bronze Hospital coverage is enough. In certain cases, Silver Hospital Cover might offer coverage as well. Policies can differ between different health funds. That is why it is important to check with them in advance.

Confusion Surrounding Medicare Rebate

Well, the confusion surrounding Medicare Rebate is due to the variables of the situation. Every single person is different and has different reasons for getting the surgery done. In certain cases, Medicare only offers a minor rebate on specific procedures. It is crucial to note that rebates are generally available for medically necessary plastic surgery procedures only. For many patients, breast reduction surgery will fall under this category.

Medicare Rebate Guidelines are very clear when it comes to Plastic & Cosmetic Surgery. Medicare does not cover ‘non-therapeutic cosmetic surgery’ NOR ‘non-therapeutic plastic surgery’ procedures. Significant Breast Ptosis after pregnancy, chronic back pain, and skin infections as a result of large breasts are regarded as chronic medical conditions.

NOTE – Medicare Rebates are subject to change and review. MBS Item Numbers are constantly reviewed and can be eliminated at any given time. If you are eligible for a Medicare rebate for breast reduction surgery, it will be best to get it done sooner rather than later.

Breast reduction is a procedure that can transform your physical appearance but also eliminate a variety of medical problems as well. If the surgery is medically necessary, there is a very big chance that you can get it covered by Medicare. Medically necessary situations include reconstruction post a mastectomy and reduction to help with the pain. Please note that Medicare will not cover elective cosmetic surgery under any circumstances. Moreover, Medicare does not cover the entire cost associated with the procedure. There are some costs you will have to pay from your own pocket. Find out more about using super to pay for your breast reduction surgery and a breast reduction surgery payment plan.

Medical References about Breast Reduction Surgery

Breast Reduction Surgery page on Mayo Clinic site
Breast Reduction Guide
Breast Reduction Surgery page on WebMD

About Dr Jeremy Hunt – Plastic Surgeon

Dr Jeremy Hunt is one of Australia’s leading specialist plastic surgeons for breast, body, face and nose surgery.

He is a member of FRACS & ASPS and has over 20 years of experience providing expert cosmetic and plastic surgery in Sydney.

Careful, considerate and honest, Dr Jeremy Hunt works with you to find a solution that is best for your body and your lifestyle. Every patient is unique and, through his expert guidance,

Dr Hunt’s personal, one-on-one service and attention to detail has given thousands of women and men from the Sydney & Wollongong NSW area and across Australia the confidence and body shape they desire.

Dr Hunt’s qualifications and education

Dr Jeremy A Hunt MBBS FRACS graduated with a Bachelor of Medicine degree from Sydney University in 1990 and is a Fellow of the Royal Australasian College of Surgeons and member of the Australian Society of Plastic Surgery. He completed a Fellowship at the prestigious University of Texas in the United States, where he learnt from some of the world’s very best plastic surgeons.

Next Step – Make an Enquiry or Request a consultation with Dr Hunt

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Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health professional.