If you’ve been wondering whether or not breast reduction Medicare cover is available in Australia, the short answer is that it can be, but it depends on a few important factors.
Breast reduction isn’t always considered a cosmetic procedure. It can also be recognised as medically necessary in some cases, which is where Medicare may be able to help.
However, getting that cover isn’t automatic. There is some specific criteria that needs to be met, and it often involves documentation, referrals, and sometimes extra costs, depending on how and where you’re having surgery.
Let’s look at how breast reduction Medicare works, what you’ll need to qualify, and what you can expect when it comes to rebates and out-of-pocket costs.
When breast reduction may be covered by Medicare
Medicare doesn’t cover every breast reduction surgery, because the procedure is sometimes done for cosmetic reasons, which fall outside of what Medicare considers medically necessary.
However, if your breast reduction is being done to address physical symptoms, you may be eligible for a rebate.
This usually applies when someone is experiencing persistent and measurable symptoms that are directly related to their breast size. That could include things like ongoing neck and back pain, shoulder grooving from bra straps, or skin irritation under the breast fold. Sometimes there are also issues with physical function – for example, if breast size is interfering with exercise or movement.
To be eligible for a Medicare rebate, your surgeon must determine that the procedure is clinically necessary and that it meets the requirements set out under a specific Medicare item number.
As of now, the relevant number is 45520, which is used for reduction mammaplasty where there is documented evidence of physical symptoms and other criteria are met.
What you’ll need for Medicare eligibility
If you’re considering having a breast reduction and you’re hoping that Medicare will cover part of the cost, you’ll first need a referral from your GP.
This referral is required if you want to see a surgeon through the Medicare system and have your consultation partially rebated.
Your surgeon will then assess whether you meet the clinical guidelines for item number 45520. Medicare requires that the symptoms are chronic, meaning they’ve been ongoing for at least six months, and that they’ve not responded to non-surgical management. You may need to provide documentation of previous treatment attempts, such as physiotherapy, pain medication, or supportive garments.
In most cases, photos will also be taken as part of your medical records, and a specific amount of tissue must be removed during surgery for it to qualify under the item number. The exact requirements can change, so it’s important that your surgeon explains what documentation is needed and how the process works under current guidelines.
Can private health insurance also help?
Even if you’re eligible for breast reduction Medicare cover, that won’t necessarily mean the procedure is fully covered. Typically, Medicare will only contribute a set amount towards some of the fees.
Therefore, if you have private health insurance with the right level of hospital cover, this can significantly reduce your out-of-pocket costs. Your private health insurance may be able to help by covering the hospital and theatre fees. Your health fund will usually need to recognise the same Medicare item number (45520).
However, there may still be some gaps. It’s a good idea to get a detailed quote from your surgeon so you can see what’s included, what Medicare will cover, what your health fund might help with, and what you’ll need to pay yourself.
How the Medicare application process works
Once you’ve received your GP referral and met with your surgeon, they’ll go through your symptoms, medical history, and any previous treatments you’ve tried.
If it looks like you meet the criteria for item number 45520, they’ll let you know what’s required for documentation, and they’ll explain how the surgery would work for you based on your anatomy.
Photos are often required to submit the claim, and you may be asked to sign forms that confirm your symptoms and treatment history.
If everything is approved, the procedure is usually booked at a hospital where your private health insurance can be used. Even with Medicare and insurance rebates, there’s still often a gap to pay, so it’s important that you know this ahead of time.
What the breast reduction surgery will typically involve
A breast reduction involves the removal of glandular tissue, fat, and skin from the breasts, and then repositioning the remaining tissue and the nipple to a higher point on the chest.
The specific technique your surgeon uses will depend on the size of the reduction, your body proportions, and any physical issues you’ve been experiencing.
The procedure is generally done under general anaesthetic and will require a hospital stay – often overnight, but sometimes longer depending on your health and how extensive the surgery is.
Dressings or surgical garments are commonly used to support the area while healing, and your surgeon will usually give you instructions about wound care, wearing support garments, and avoiding certain movements or activities for a while.
What recovery might involve
Recovery after breast reduction surgery varies a little depending on the extent of the tissue removal and your individual health.
For most patients, it’s a few weeks before things start to feel more manageable day-to-day, although it will take longer before you’re ready to go back to certain activities.
You’ll be given advice on things like when you can lift your arms properly, when to return to work, and when to resume any physical activity. Follow-up appointments are usually scheduled in the weeks after surgery to check how everything is progressing.
There may be swelling and bruising early on, and there will be scars around the nipple and lower breast area. These are permanent but usually settle down in appearance over time. Your surgeon will let you know what to expect based on how your incisions were made.
Ask all of your breast reduction questions: See Dr Norris at Form & Face in Sydney (Bondi Junction) and Bella Vista.
If you’re looking for a breast reduction surgeon and are wondering if you may be eligible for a Medicare rebate, discussing your situation with Dr Norris can help.
After receiving a referral from your GP first, you can ask any and all of your questions about the breast reduction procedure, Medicare and private health cover during a consultation at Form & Face.
You are welcome to enquire with our team to book in your consultation at our Sydney (Bondi Junction) or Bella Vista locations.