Medicare for Breasts with Congenital Deformities

Step-by-Step Guide to Getting Medicare Coverage for Breasts Procedures

Living with a congenital breast deformity can feel like a lonely journey, but you’re not alone. Whether you’ve been diagnosed with Poland Syndrome, tuberous breasts, severe asymmetry, or another congenital condition, thousands of Australian women share similar experiences and challenges.

You might have spent years feeling uncertain about your treatment options or worried about the financial aspects of corrective procedures. Perhaps you’ve wondered whether Medicare could help, but found yourself overwhelmed by the complex healthcare system and medical terminology.

That’s precisely why we’ve created this resource. As you navigate through the Australian healthcare system, we understand that you need clear, accurate information about Medicare coverage for breast reconstruction and correction procedures. You deserve to know your options, rights, and the support available to you. We’ll help you understand the Medicare benefits scheme, decode the relevant item numbers, and explore the various pathways available for treatment.

What Are Congenital Breast Deformities?

When you hear the term ‘congenital breast deformity’, it refers to any structural abnormality of the breast that’s present from birth, even if it becomes apparent only during development. These conditions can range from subtle variations to more significant differences in breast development, and it’s essential to understand that they’re medical conditions, not just cosmetic concerns.

The most commonly diagnosed conditions include:

Poland Syndrome

This rare condition typically affects one side of the chest wall and breast. If you have Poland Syndrome, you might notice underdevelopment or absence of chest wall muscles, breast tissue, and nipple changes. It can also affect the shoulder, arm, and hand on the same side. The condition is more common in women but can affect people of any gender.

Tuberous Breast Deformity

Also known as tubular breasts, this condition affects breast development during puberty. You might notice unusual breast shape, with a narrow breast base, enlarged areolas, and minimal lower pole development. The condition can affect one or both breasts and varies in severity. Women with tuberous breasts experience can physical discomfort and challenges with everyday activities.

Breast Asymmetry

While some degree of asymmetry is normal, significant developmental asymmetry can cause both physical and emotional challenges. This condition involves a marked difference in size, shape, or position of the breasts. When the difference is greater than one cup size or involves notable shape variations, it’s considered a medical condition rather than normal variation.

Other Developmental Conditions

You might be affected by other conditions such as:

Complete absence of breast tissue (amastia)
Severe underdevelopment (hypoplasia)
Extra breast tissue (polymastia)
Abnormal nipple development
Chest wall deformities affecting breast development

Being aware of your specific condition is the first step towards seeking appropriate treatment. Medical documentation of these conditions is essential for Medicare coverage, as it helps distinguish between reconstructive needs and cosmetic desires. Your GP or specialist can provide detailed information about your specific condition and guide you through the diagnostic process required for Medicare benefits.

Medicare Coverage

Every year, hundreds of Australians face the challenge of seeking treatment for congenital breast deformities. While Medicare offers comprehensive coverage for these procedures, many patients find themselves overwhelmed by the complexity of the healthcare system. Here is everything you need to know about accessing the care you deserve, turning what can feel like an intimidating journey into clear, actionable steps.

Medicare Item Numbers for Congenital Breast Deformities

The Medicare Benefits Schedule (MBS) includes different item numbers specifically related to breast reconstruction and correction of congenital deformities:

Medicare Benefits Schedule – Item 45060

This single-stage procedure covers bilateral mastopexy for symmetrical tubular breasts or combination surgery involving implants, mastopexy, or reduction. For implant procedures, a minimum 10% volume difference between implants is required. The surgery addresses volume differences of at least 20% in normal breasts or 10% in tubular breasts or those with high inframammary folds. Clinical documentation must include photographic and/or diagnostic imaging evidence. The Medicare benefit is 75% of the $1,448.30 fee ($1,086.25), and this item can be claimed once per surgical occasion. Anaesthetist and surgical assistance fees apply separately.

Medicare Benefits Schedule – Item 45061

This item covers the first stage of a two-stage developmental breast abnormality correction. The procedure includes bilateral surgery combining tissue expanders, mastopexy, or reduction mammaplasty. It requires documented volume differences of at least 20% in normal breasts or 10% in tubular breasts or those with high inframammary folds. Supporting photographic and/or diagnostic imaging evidence must be included in patient records. Medicare provides a 75% benefit of $1,086.25 from the $1,448.30 fee, claimable once per surgical occasion. Anaesthetist and surgical assistance fees apply separately.

Medicare Benefits Schedule – Item 45062

This item covers the second stage of a two-stage developmental breast abnormality correction. The procedure includes exchanging tissue expanders for implants (requiring minimum 10% volume difference), combined with mastopexy or reduction mammaplasty. Volume differences must be documented at 20% for normal breasts or 10% for tubular breasts or those with high inframammary folds. Clinical documentation through photographic and/or diagnostic imaging is required. Medicare provides a 75% benefit of $786.05 from the $1,048.05 fee, claimable once per surgical occasion. Anaesthetist and surgical assistance fees apply separately.

Medicare Benefits Schedule – Item 45524

This item covers single-breast augmentation for either breast cancer cases or developmental abnormalities. For developmental cases, documented volume differences must show at least 20% in normal breasts or 10% in tubular breasts or those with high inframammary folds. The Medicare benefit is 75% of the $844.90 fee ($633.70), claimable once per surgical occasion unless associated with items 45006 or 45012. Anaesthetist and surgical assistance fees apply separately.

Medicare Benefits Schedule – Item 45528

This item covers bilateral breast augmentation for reconstructive purposes due to developmental malformation (excluding hypomastia), breast disease/trauma (excluding previous cosmetic surgery), or amastia from congenital endocrine disorders. Clinical documentation must include photographic or diagnostic imaging evidence. Medicare provides a 75% benefit of $950.40 from the $1,267.20 fee, unless associated with items 45006 or 45012. Anaesthetist and surgical assistance fees apply separately.

Medicare Benefits Schedule – Item 45534

This item covers single-breast fat grafting (harvesting, preparation, and injection) for breast cancer treatment defects with ≥20% asymmetry, post-treatment pain, or poor prosthetic coverage; preparation of post-mastectomy thin/irradiated skin flaps; breast reconstruction; or developmental disorders. Photographic/diagnostic imaging evidence required. Maximum 4 services per breast. Medicare benefit is 75% of $719.70 fee ($539.80), excluding services under items 45006 or 45012. Anaesthetist fees apply separately.

Medicare Benefits Schedule – Item 45535

This item covers bilateral fat grafting (harvesting, preparation, and injection) for breast cancer treatment defects with ≥20% asymmetry, post-treatment pain, or poor prosthetic coverage; preparation of post-mastectomy thin/irradiated skin flaps; breast reconstruction; or developmental disorders. Photographic/diagnostic imaging evidence required. Maximum 4 services total. Medicare benefit is 75% of $1,259.55 fee ($944.70), excluding services under items 45006 or 45012. Anaesthetist fees apply separately.

Eligibility Requirements

To qualify for Medicare benefits, you’ll need to meet several criteria:

Documented medical diagnosis of a congenital condition
Referral from your GP to a specialist plastic surgeon
Clinical photographs and measurements
Letter of medical necessity from your specialist
Evidence that the condition causes functional impairment or significant psychological distress

Required Documentation

Your medical team will need to prepare:

Detailed clinical notes documenting the condition
Photographic evidence
Measurements and assessments
Psychology reports (if applicable)
Treatment plan outlining the medical necessity

Coverage Limits

Being aware of Medicare’s coverage limits is essential:

Medicare typically covers 75% of the scheduled fee for inpatient procedures
Additional costs may apply for hospital stays, anaesthesia, and auxiliary services
Some aspects of your treatment might require private health insurance or out-of-pocket payment

Step-by-Step Guide to Medicare Coverage for Breasts with Congenital Deformities

Here’s your step-by-step guide to accessing the care you need.

Step 1: Initial Consultation and Diagnosis
Start with your GP

Book a longer consultation to discuss your concerns
Request a thorough examination
Obtain referrals to relevant specialists
Begin documenting your condition

Specialist Consultation

Meet with a plastic surgeon experienced in congenital breast reconstruction
Undergo clinical photography and measurements
Discuss treatment options and expected outcomes
Obtain detailed medical reports

Step 2: Building Your Case
Medical Documentation

Collect all relevant medical history
Ensure proper diagnostic coding
Gather supporting evidence from other healthcare providers
Maintain copies of all correspondence

Treatment Planning

Work with your surgeon to develop a comprehensive treatment plan
Understand the proposed surgical techniques
Discuss timing and staging of procedures
Consider recovery requirements

Step 3: Medicare Application Process
Pre-approval

Submit all required documentation
Include clinical photographs and measurements
Provide supporting psychological assessments if applicable
Allow sufficient processing time

Healthcare Team Coordination

Ensure all providers are aware of the treatment plan
Coordinate between GP, surgeon, and other specialists
Maintain clear communication channels
Keep records of all Medicare correspondence

Finding a Plastic Surgeon for Your Procedure

When seeking a surgeon, qualifications to look for include FRACS (Fellow of the Royal Australasian College of Surgeons) certification, specific experience in congenital breast reconstruction, and membership in the Australian Society of Plastic Surgeons. The surgeon should also demonstrate a strong track record with cases similar to yours.

During your consultation, discuss the surgeon’s experience with your specific condition, their proposed surgical techniques, and expected outcomes including any limitations. It’s important to understand their Medicare billing practices and which hospitals they are affiliated with. These conversations will help ensure you choose a qualified surgeon who meets your needs and can provide the best possible care for your situation.

Timeline Expectations

Understanding the typical timeline helps manage expectations:

Pre-approval Phase: 4-8 weeks

Initial consultations
Documentation gathering
Medicare submission and approval

Surgical Planning: 2-4 months

Pre-operative assessments
Hospital booking
Insurance coordination

Recovery Period: 6-12 months

Initial recovery: 2-6 weeks
Full tissue settling: 6-12 months
Possible staged procedures

Remember that while this process can seem overwhelming, your healthcare team is there to support you. Don’t hesitate to ask questions or seek clarification at any stage of your journey. The key to successful navigation is staying informed, organised, and proactive in your approach to treatment.

Cost Considerations

The financial aspects of breast surgery for congenital deformities are important for planning your treatment journey. While Medicare provides some support, it’s important to have a clear picture of all potential costs.

Medicare Rebates

Like we mentioned already, the Medicare rebate typically covers 75% of the scheduled fee for surgical procedures. However, it’s essential to note that the scheduled fee often differs from the actual fees charged by surgeons. For example, if your procedure’s scheduled fee is $5,000, Medicare would contribute $3,750, but your surgeon’s total fee might be higher.

Private Health Insurance Role

If you have private health insurance, it can help cover:

Hospital accommodation costs
Theatre fees
Prostheses (such as implants)
Gap payments for medical services

Check your policy’s waiting periods and ensure your level of cover includes plastic and reconstructive surgery.

Out-of-pocket Expenses

You may need to budget for:

Initial consultation fees
Gap payments for surgical fees
Anaesthetist fees
Post-operative garments
Follow-up appointments
Additional procedures if required

Common Myths about Medicare for Breasts with Congenital Deformities Debunked

Myth: “Only severe cases qualify for Medicare”
Fact: Medicare considers each case individually. The key factor is medical necessity, not necessarily severity alone. Even moderate cases can qualify if properly documented and deemed medically necessary.

Myth: “You need private health insurance to access treatment”
Fact: While private health insurance can provide additional benefits, Medicare coverage is available regardless of private insurance status. Public hospital treatment options exist, though waiting times may be longer.

Myth: “All plastic surgeons can perform these procedures”
Fact: Look for surgeons specifically experienced in reconstructive surgery for congenital breast deformities. Specialised expertise is crucial for optimal results.

Myth: “One surgery will fix everything”
Fact: Many cases require staged procedures or revisions. Your treatment plan should account for potential future procedures and ongoing care.

Common Misconceptions about the Process

“The process is too complicated to navigate” While the system can seem complex, your healthcare team can guide you through each step. Breaking down the process into manageable stages makes it less overwhelming.
“If one surgeon says no, that’s the end”Getting second opinions is common and often valuable. Different surgeons may have varying approaches and experience levels with specific conditions.
“Medicare will cover identical procedures on both sides” Coverage depends on medical necessity. Symmetry procedures might be covered if part of the overall reconstruction plan, but each case is assessed individually.

FAQs about Medicare Coverage for Congenital Breast Deformities

Is this just cosmetic surgery?

No. Correction of congenital breast deformities is considered reconstructive surgery, not cosmetic surgery. The main difference lies in the medical necessity of the procedure to restore normal appearance and function. Medicare recognises these conditions as medical issues requiring correction, unlike elective cosmetic procedures.

Do I need to prove psychological distress to qualify?

While psychological impact can strengthen your case, it’s not the sole determining factor. The physical presentation of your condition, documented by your specialist, is the primary consideration. However, if you’re experiencing psychological distress, including documentation from a mental health professional can support your application.

Can I travel interstate for surgery?

Yes, Medicare covers eligible procedures anywhere in Australia. You might consider travelling to access surgeons with specific expertise in your condition. However, keep in mind:

Additional travel and accommodation costs aren’t covered by Medicare
Post-operative care and follow-up visits need careful planning
Your local GP can assist with ongoing care coordination
Some surgeons require multiple pre-operative visits
Recovery time away from home needs consideration
Interstate specialists may require referrals from your local GP

What if my condition changes or worsens after initial treatment?

Medicare coverage extends to medically necessary revisions or additional procedures. This includes:

Complications requiring surgical correction
Asymmetry developing over time
Changes due to pregnancy or weight fluctuations
Implant-related issues
Progressive conditions requiring staged treatment

However, each additional procedure requires fresh documentation and approval. Maintain regular follow-up with your healthcare team to monitor any changes and document progression if needed. Early intervention often leads to better outcomes and stronger Medicare claims for subsequent procedures.