Will Medicare Cover Breast Reduction Surgery?

Breast Reduction

Will Medicare and My Private Health Insurance Cover My Breast Reduction Surgery?

You may be wondering whether your private health insurance coverage in addition to Medicare will cover a portion or the entirety of your Breast Reduction Surgery costs.

Breast surgery and Medicare eligibility is very limited with Breast Reduction Surgery being one of the exceptional procedures that is listed on the Medicare Benefits Schedule meaning that your private health insurance will cover some or all of your hospital costs, and Medicare will make a small contribution to the medical costs associated with the private Surgeon and Anaesthetist.

In some cases, patients may even use their Superannuation to fund their surgery by applying for an early release of funds on compassionate grounds for medical treatment. Why is that the case?

There are often numerous health concerns that relate to a patient’s reasons for wanting Breast Reduction Surgery, including:

  • relief from chronic skin infections under the breasts (‘intertrigo’)
  • relief from back, neck and shoulder pain caused by the heaviness of the breasts
  • remedy other breast-weight related health conditions that affect quality of living, for example going to the gym, and jogging
reduction Surgery

Will Medicare Cover My Breast Reduction?

Patients who have heavy breasts that are causing them chronic health conditions represent a medical reason for having breast reduction surgery. A referral from your GP documenting the pain and suffering caused by your breasts and any previous treatments underwent to try to alleviate the discomfort is proof of the chronic conditions caused by your breasts.

With the information from your GP and a physical examination, Dr Briggs will be able to determine your eligibility for the Medicare Item number.

The criteria for a Medicare Claim for Breast Lift Surgery is outlined below

(a) for patients with macromastia (large breasts) and experiencing pain in the neck or shoulder region; and

(b) not with the insertion of any prosthesis – this means you cannot have an implant put in when having the reduction to be able to claim the rebate

Why Should I Consider A Breast Reduction?

Breast Reduction surgery can be a life-changing procedure for patients. It can prevent or treat recurring problems related to heavy breasts giving patients overall better quality of life

Most breast reduction patients are happy to find they have a new lease on life –ranging from better sleep to being able to participate in new activities e.g. fitness classes which they have been unable to attend in the past.

Further benefits from Breast Reduction surgery include being able to wear fashionable bras, swimwear and other items of clothing you formerly felt weren’t suited or too uncomfortable for your fuller breasts.

To be eligible to claim your surgery on Medicare, you will need a Medical Referral from your General Practitioner. This can be obtained before your initial consult with Dr Briggs or after your initial consult but before your pre-operative appointment.

Why Is the Medicare Rebate Question for Breast Surgery So Confusing?

The answer to this question can often be confusing for most patients seeking cosmetic surgery.

  • That is because it will vary depending on the patient and the procedure required.
  • Medicare will sometimes offer a minor rebate on some procedures.
  • Rebates are generally available only for reconstructive plastic surgery or what is deemed ‘essential’ medically necessary surgery.
  • Most breast procedures do not qualify under this category and are seen to be medically unnecessary, but Breast Lift and Breast Reduction may fall under this category for many patients.

When it comes to Plastic & Cosmetic Surgery, the Medicare rebate guidelines are very clear; Medicare will not cover ‘non-therapeutic cosmetic surgery’ NOR ‘non-therapeutic plastic surgery’ procedures. Significant Breast Ptosis after pregnancy and chronic Back Pain or Skin Infections related to large breasts are chronic medical conditions, however, and may lead to eligibility for a minor rebate.

Breast Reduction Surgery and The Medical Benefits Schedule (MBS)

If you possess the required documentation proof for your Breast Reduction Surgery and you meet the current Medicare criteria, then yes, you may qualify for a small rebate from Medicare for your procedure. MBS changes at the end of 2018 included additional photographic proof, examination evidence/reporting documentation and stricter patient criteria for Medicare rebates for Breast Reduction Surgery. Similarly, other procedures relating to women’s health were also impacted.

Your eligibility may depend on the following Medicare criteria

(a) for patients with macromastia (large breasts) and experiencing pain in the neck or shoulder region; and

(b) not with insertion of any prosthesis – this means you cannot have an implant put in when having the reduction to be able to claim the rebate

Additionally, you may be eligible for rebates on your surgery and hospital cover from your Private Health Insurance provider. This will, however, only apply if your condition meets the criteria for a Medicare Item Number and that you have adequate coverage for the procedure. Most Breast Reductions are covered under Bronze hospital cover but there are instances where Silver hospital cover may be required. You should always check directly with your Health Fund regarding your policy and whether you are covered for the Medicare item number.

It’s important to recognise that Medicare items and rebate eligibility criteria for Breast Reduction Surgery are subject to change in an instant, with very little notice or forewarning. Therefore, you should discuss your eligibility with Dr Briggs and his team as they will have the most up-to-date information on hand.

There Are Often Crucial Medical and Health Reasons That Lead Women To Seek Breast Reduction Surgery, These May Include:

  • Chronic skin infections.
  • Excess perspiration around or under breasts.
  • Difficulty purchasing bras and other items of clothing.
  • Challenges when exercising caused by large, pendulous breasts.
  • Back pain, neck pain or shoulder pain related to breast weight, breast volume or breast ptosis.
  • Other breast-weight related health conditions that impact your health and quality of life.

If you are chronically suffering from one or more of the above symptoms due to your breast weight or volume, your Breast Reduction surgery may be eligible for a rebate. However, it will always depend on if you meet the criteria as to whether you are eligible or not.

If I Am Not Eligible for A Medicare Rebate, Will My Private Health Fund Cover My Breast Procedure?

Private Health Funds only ever cover a procedure if it has an MBS item number, the patient meets current Medicare eligibility criteria, and a Medicare Statement of Claim and Benefit has been processed. Therefore, you must meet the criteria for a Medicare rebate to seek cover from your Health Fund. A general rule is if Medicare will not pay, private health will not pay.

If Medicare or a Health Fund do not cover my breast reduction, how much will my procedure cost?

The cost of having a Breast Reduction performed by a Plastic Surgeon in Melbourne will vary. This is because each procedure is fully customised to meet your anatomy, specific needs and desired surgical outcome. Dr Brigg and his team can help you with assessing your eligibility for coverage by MBS or your health fund. They can also assist you in understanding the cost and risks of surgery.

To access your eligibility to claim a Medicare rebate for your Breast Reduction Surgery, visit your GP or other specialist and ask for a referral to Dr Briggs.

You can also speak to our knowledgeable reception team, who are available to answer your questions.  Simply phone us on 08 9381 9300.

Will My Super Pay for Plastic Surgery

Can I Use My Super Fund for Breast Reduction Surgery?

Some patients may consider requesting an early release of superannuation funds to help pay for Breast Reduction surgery, however, before doing so, it is important to note that:

So Will Medicare Cover My Breast Reduction Plastic Surgery?

YES – Medicare Rebates may apply for Breast Reduction / Reduction Mammoplasty – but strict criteria must be met.  There is no guarantee until you have been examined by Dr Briggs but ask your General Practitioner for information to see if you qualify or book your consultation with Specialist Plastic Surgeon Dr Briggs after getting a referral from your GP.

About Our Plastic Surgeon – Dr Patrick Briggs FRCS (Plast)

Dr Patrick Briggs Best Perth Cosmetic Surgeon

Dr Patrick Briggs offers high quality, natural-looking plastic and cosmetic surgery results and is vastly experienced in BreastBody and Face Surgery having performed over 4500 Surgeries in private practice.  With world-wide expertise Dr Patrick Briggs is an expert in breast, face and body surgery for men and women.


Book your Initial Surgery Consultation

  • Email us or Call on 1300 264 811  to arrange your initial consultation appointment with Dr Patrick Briggs.
  • A Referral from your GP or specialist is helpful but NOT essential – you can have a consultation without a GP Referral.
  • Your initial Consultation Booking Fee with a Specialist Surgeon is usually $300 and your booking fee is paid ahead of your appointment and will secure your consultation date. You can pay by phone by calling us to affirm payment or book an appointment time. We have online payment methods if necessary.

What to Bring to your Plastic Surgeon Consultation

  • Bring a friend or relative to help discuss the information and your choices
  • Take notes and read the literature provided  on the procedures thoroughly
  • Want more information before scheduling your consultation?

Request more information about the procedure – call or contact us

Please contact us using our contact form to arrange to book a consultation with our Specialist Plastic Surgeon or to speak with our reception staff who will be able to provide you with further information.

Send an enquiry today or phone 03 8849 1400  during clinic hours, Monday – Friday 9am – 5pm