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Will Medicare Cover My Breast Reduction Surgery on the Gold Coast and Ballina

A breast reduction can surgically reduce the size and weight of the breasts by removing excess tissue and sometimes repositioning the nipples and areolae. When it comes to the costs of breast reduction surgery, Medicare cover may be possible if the procedure is considered medically necessary. Essentially, whether or not Medicare can provide cover for your breast reduction will depend on your reasons for undergoing the procedure, and if you can meet Medicare’s eligibility requirements.

In this blog, we’ll break down how Medicare may cover your procedure’s costs and the factors to consider. If you want to discuss the details of your personalised breast reduction procedure, you’ll first need to meet with your surgeon (Dr Layt or Dr Cheng) for a consultation at The Layt Clinic in Southport on the Gold Coast, or at our Ballina location.

Firstly, what is a breast reduction?

To reduce the size of the breasts, a breast reduction removes excess breast tissue, fat and skin. Sometimes, a breast reduction includes the surgical repositioning of the nipples to suit the new breast shape and size. The procedure is highly tailored to your needs, with a thorough plan that is based on the new breast size you want or need to achieve and the current condition of your breasts.

While you may like to undergo the procedure for cosmetic reasons (such as to change the size of the breasts in order to achieve a different appearance in the breasts), you may also undergo the procedure for reasons that are typically considered to be medically necessary.

Even though you may undergo a breast reduction for medical reasons, highly experienced plastic surgeons will still carefully consider the aesthetics of your results.

What are some medically necessary reasons to have a breast reduction?

There are a variety of reasons a patient may undergo a breast reduction that can be considered medically necessary.

A common medically necessary reason to have a breast reduction is to resolve pain caused by heavy breasts, which may be putting strain on the neck, shoulders and back. As well as pain, the weight of the breasts can also cause muscle tension and poor posture, which can be difficult to treat without addressing the main cause of the issue.

The size and weight of the breasts can also cause mobility issues and general discomfort. It can prevent patients from being able to exercise and even feel comfortable completing other daily activities.

When the size of the breasts prevents patients from keeping the skin underneath sufficiently clean and dry, it can lead to skin irritation and even infections in the area. Treating these skin conditions as they occur without addressing the breasts can be challenging, like attempting to treat pain caused by the weight of the breasts.

These are just some common examples, and every patient’s experience is unique. Generally, pain, discomfort, and other health or wellbeing-related concerns caused by the size of the breasts can be medically necessary reasons to undergo a breast reduction.

If you are undergoing surgery for one (or more) of these medically necessary reasons, you may be eligible for breast reduction surgery Medicare cover.

An overview of Medicare’s requirements: Medicare Benefits Schedule Item Numbers

The key to being eligible for breast reduction surgery is having a medically necessary reason for undergoing the procedure. For a reason to be medically necessary, it needs to interfere with your health, well-being, and quality of life.

Medicare outlines their requirements in the relevant Medicare Benefits Schedule (MBS) Item Number. There are multiple Medicare Item Numbers for a breast reduction, allowing patients with differing circumstances to find the number that applies to their needs.

When you consult with your GP, specialist or plastic surgeon, they can find the right Medicare Item Number based on your personal circumstances. You can read about each item number for a breast reduction on MBS Online.

For example, MBS item number 45523 is for a breast reduction that includes the surgical repositioning of the nipple, performed to address chronic neck or shoulder pain. For a breast reduction that is performed in the context of breast cancer or developmental abnormality of the breast, this will be item number 45520. Your item number will also include information on the amount of cover you will receive from Medicare.

While researching Medicare’s requirements can help you to gain an understanding of how the process works, you should always wait until consulting with your GP or specialist to find out if you are eligible for cover. Your GP or specialist will be able to provide you with personalised advice and accurately measure your needs against Medicare’s requirements.

What breast reduction costs will Medicare cover?

For eligible patients, Medicare can cover a portion of the total breast reduction surgery costs.

Costs that can be covered include a portion of your surgeon’s fees, anaesthesia costs, and hospital fees if you undergo the procedure in a public hospital. If you do undergo your procedure in a private hospital, Medicare can cover a portion of your surgeon’s and anaesthesia fees – if you have private health cover, your provider may be able to assist with the private hospital fees.

The amount of your breast reduction costs that Medicare can cover is outlined on your MBS Item Number. For example, for item numbers 45523 or 45520 as we mentioned earlier, this amount is typically 75% of the MBS scheduled fees. Private surgeons will quote private fees, which are larger than a scheduled fee, so only the portion of the MBS scheduled fee will be reimbursed by Medicare. If you have private health cover, you may be able to claim the full amount or a portion of the gap. It is important to speak to your private health insurer about your level of cover prior to undergoing surgery. You should also discuss your personal circumstances with your GP or specialist for information on your cover.

While Medicare can be of great assistance when it comes to your breast reduction costs, it’s important to consider the out-of-pocket costs that will still be required. After your consultation with your plastic surgeon, you will receive a personalised quote, detailing your total costs. Your quote will allow you to prepare for the costs of your procedure, before committing to undergoing your breast reduction.

How to start the process of applying for your breast reduction surgery Medicare cover

The first step to begin the process of applying for breast reduction Medicare cover is typically a referral from a GP or specialist.

To make sure that a patient is eligible for cover, it’s important that the patient can clearly demonstrate the medical need for the procedure. Your GP or specialist will be able to thoroughly assess your symptoms and health concerns, as well as assess if these concerns can be clearly linked to the size and/or weight of the breasts. Your referral will act as an official document that outlines the medical necessity of the procedure.

When you’re ready, you’ll then have a consultation with a qualified plastic surgeon, such as Dr Layt or Dr Cheng if you’re based on the Gold Coast or are happy to travel to the Gold Coast. During your consultation, your surgeon will assess your condition further, and be able to put together a treatment plan. Your surgeon can discuss your eligibility for Medicare cover further, confirming whether or not you can meet Medicare’s requirements.

The Layt Clinic on the Gold Coast and Ballina: Plastic Surgeon’s Dr Layt and Dr Cheng

Choosing qualified plastic surgeons is key to not only receive breast reduction surgery Medicare cover, but to achieve high quality results, based on your unique needs.

With locations in Southport on the Gold Coast and Ballina, The Layt Clinic has a team of highly experienced and qualified plastic surgeons, registered nurses, and aestheticians.

Dr Craig Layt is a Specialist Plastic and Reconstructive Surgeon. With his extensive training and experience, he has been providing Plastic and Reconstructive Surgery services to the Gold Coast and Northern Rivers Regions for over 23 years.

Dr Paul Cheng is a Specialist Plastic, Aesthetic and Reconstructive Surgeon. He extensively trained in New Zealand before relocating to the Gold Coast, where he now provides specialist service in the private sector at The Layt Clinic.

If you’re ready to discuss the details of your breast reduction procedure, we welcome you to contact our team and book your consultation with one of our qualified and experienced plastic surgeons.

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