Will Medicare Cover My Breast Reduction?

08 Nov Will Medicare Cover My Breast Reduction?

Medicare Rebate for Breast Reduction Surgery

Breast Reduction surgery, for many, is not just about aesthetics, it’s about alleviating physical discomfort. In Australia, there’s a common misconception that such surgeries are purely cosmetic and therefore are not covered by Medicare or private health insurance. However, this isn’t entirely true. Let’s break down the process and understand how you can potentially get a Medicare rebate for your Breast Reduction surgery.

Dr. Guy Watts is an experienced plastic surgeon based in Perth, Australia and is a good option for your Breast Reduction surgery.

What Is Breast Reduction Surgery?

Breast Reduction surgery, often referred to as Reduction Mammoplasty, is a medical procedure designed to reduce the size of your breasts. This surgery is not just about altering appearance but also about addressing the physical discomfort that can come with having overly large breasts.

At its core, Breast Reduction surgery involves the removal of excess breast tissue, fat, and skin. This results in breasts that are more in proportion with the rest of your body and can alleviate many of the discomforts associated with larger breasts. The exact method and approach will vary based on your individual needs and the recommendations of your plastic surgeon. Some might need more tissue removed, while others might require a more subtle reduction.

Benefits of Breast Reduction Surgery

• Physical Relief: One of the primary reasons many opt for this surgery is the physical discomfort that comes with having larger breasts. This can include: chronic back and neck pain, shoulder indentations from bra straps, skin irritation beneath the breasts and more
• Enhanced Mobility: With smaller breasts, you might find it easier to engage in physical activities that were previously challenging or uncomfortable. Whether it’s running, swimming, or even just daily tasks, the reduction can make a noticeable difference
• Improved Proportion: The surgery can result in breasts that are more proportionate to your body frame

Getting Medicare Cover for Breast Reduction Surgery

Medicare in Australia recognises the medical necessity of Breast Reduction surgery for some individuals. This means that if you meet certain criteria, you might be eligible for a rebate. There are specific item numbers that relate to Breast Reduction surgery. If your plastic surgeon believes that the procedure is medically necessary for you, they can use this item number when billing. This could entitle you to a rebate from Medicare.

The term “medical necessity” might sound a bit vague, but in the context of Breast Reduction, it typically refers to situations where the size of one’s breasts causes physical issues. This could be chronic back pain, neck pain, or even skin conditions that arise due to excessive sweating and chafing.

Before any decisions are made, you’ll need to have a detailed consultation with your plastic surgeon. Dr. Watts will assess your situation, listen to your concerns, and determine if the surgery is a medical necessity for you. His recommendation plays a pivotal role in whether Medicare and your private health insurer will offer coverage.

Keep in mind that you will need a GP referral to see Dr. Watts, especially if you want to get a Medicare rebate for your Breast Reduction surgery. While Dr. Guy Watts is a renowned name in the field, it’s essential to note that he does not offer free Breast Reduction surgery. However, with the potential subsidies from Medicare and private health insurers, the overall cost can be reduced for eligible patients.

Medicare Rebate for Breast Reduction Surgery

Navigating the world of medical rebates can sometimes feel like a maze. However, when it comes to Breast Reduction surgery in Australia, understanding the Medicare Benefits Schedule (MBS) codes and related terms can make the process easier. Let’s break down the essentials to give you a clearer picture.

MBS Codes Applicable for Breast Reduction Surgery

• Medicare Item Number 45523: This is the primary item number associated with Breast Reduction surgery. This item number refers to a Bilateral Breast Reduction (both breasts) that includes the surgical repositioning of the nipple. When your plastic surgeon believes the procedure is medically necessary, they will use this code when billing, potentially entitling you to a rebate.

Other Relevant Codes: While 45523 is the most commonly referenced code, there might be other item numbers that Dr. Watts uses based on the specifics of your procedure:

• Code 45520: Unilateral breast reduction, which involves the surgical repositioning of the nipple
• Code 45522: Unilateral breast reduction without the surgical repositioning of the nipple

Definitions of Terms Related to Breast Reduction

• Reduction Mammoplasty: This is the medical term for Breast Reduction surgery. It refers to the surgical procedure that reduces the size of the breasts by removing excess tissue, fat, and skin
• Medical Necessity: This term is pivotal when seeking a Medicare rebate. It means that the surgery isn’t just for cosmetic reasons but is required to alleviate physical discomfort or health issues. As discussed, conditions like chronic back pain, neck pain, or skin irritations can be deemed medically necessary reasons for the surgery
• Rebate: In the context of Medicare, a rebate is the amount of money you can claim back for specific medical services. The exact amount can vary based on the procedure and the MBS item number used
• Out-of-Pocket Costs: These are the expenses that aren’t covered by Medicare or private health insurance. Even with a rebate, there will be some costs you’ll need to cover yourself. It’s essential to get a clear understanding of these potential costs before going ahead with the procedure

Is My Breast Procedure Covered By Private Health Fund?

Private health funds may cover your procedure under specific circumstances:

• The patient must align with the current Medicare eligibility standards and possess an MBS item number
• Strict criteria for a Medicare rebate must be met to qualify for health fund coverage

Cost If Self-Funded?

When considering a Breast Reduction and funding it yourself, several factors can influence the overall cost. Here’s a breakdown to help you get a clear picture:

Consultation Fees

• Some surgeons charge for an initial consultation, while others might offer it for free

Plastic Surgeon’s Fees

• This is the fee charged by the plastic surgeon for performing the procedure
• It can vary widely depending on the plastic surgeon’s location, and the complexity of the surgery

Anaesthetist’s Fees

• An anaesthetist is responsible for administering anaesthesia during the surgery
• Their fee can depend on the duration and complexity of the surgery

Hospital and Operating Room Charges

• These charges cover the use of the hospital facilities and equipment
• Costs can differ based on the hospital’s location, reputation, and the length of your stay

Post-surgery Care

• After the surgery, you might need medications, dressings, or follow-up visits
• These can add to the overall cost

Additional Tests or Procedures

• Sometimes, additional tests like blood work or imaging might be necessary before the surgery
• These tests can have separate charges

FAQs about Breast Reduction Surgery and Medicare

Why is the distinction between “elective” and “medically necessary” so important when seeking coverage for Breast Reduction through Medicare?

• The distinction is pivotal as Medicare predominantly covers treatments deemed essential for the patient’s health. If a Breast Reduction surgery is considered “elective”, meaning it’s primarily for aesthetic purposes and isn’t a medical necessity, the procedure will not receive Medicare coverage. On the other hand, if the surgery is “medically necessary” to alleviate or treat a medical condition such as chronic pain, discomfort, or physical hindrance due to large breasts, then there’s a higher likelihood that Medicare will provide coverage. It’s vital to ensure your plastic surgeon documents the medical reasons for the procedure to increase the chances of coverage.

What happens if my Breast Reduction procedure isn’t covered by Medicare?

• If Medicare doesn’t cover your procedure, you’ll likely need to shoulder the costs out-of-pocket. It’s essential to request a detailed cost breakdown from your medical provider to fully understand the expenses involved.

Are there any other hidden or additional costs I should be aware of when considering Breast Reduction?

• Yes, while the surgical procedure itself is a significant expense, there may be other associated costs. These can include consultation fees, hospital fees, anaesthesia fees, post-operative care, and any unforeseen complications or additional treatments that might arise.
• Always ask your plastic surgeon for a comprehensive list of all potential expenses so you can prepare accordingly.

How do I determine if my Breast Reduction surgery is “medically necessary”?

• A consultation with a qualified plastic surgeon is the first step. Dr. Watts will assess your physical condition, medical history, and any symptoms you might be experiencing due to the size and weight of your breasts.
• Common reasons that might deem the surgery medically necessary include chronic neck, back, or shoulder pain, skin irritations, bra strap indentations, and functional hindrances in daily activities. If the plastic surgeon determines the surgery is essential for your health, he will document this in your medical records and reflect it in your quote.

Are all Breast Reduction surgeries assigned the same Medicare Item Number, or do the specifics of the procedure matter?

• The specifics of the procedure indeed matter. As detailed earlier, there are different item numbers under Medicare, such as Code 45523 for Bilateral Breast Reduction with nipple repositioning, Code 45520 for Unilateral Breast Reduction with nipple repositioning, and Code 45522 for Unilateral Breast Reduction without nipple repositioning.
• It’s imperative to understand which code your plastic surgeon will use based on the procedure’s nuances, as this will affect the potential rebate you might receive.

Further Reading about Breast Surgery with Dr. Guy Watts

• Read Dr. Watts’ Blog about Exercising after Breast Reduction
• Read Dr. Watts’ Blog about Top 10 Methods to Reduce Scars after Breast Reduction Surgery
• Read Dr. Watts’ Blog about Breast Reshaping with Fat Grafting
• Read Dr. Watts’ Blog about Solutions for Heavy Breasts- Breast Reduction
• Read Dr. Watts’ Breast Augmentation Perth Surgery page
• Read Dr. Watts’ Breast Reduction Surgery page
• Read Dr. Watts’ Breast Lift Surgery page
• Read Dr. Watt’s Blog about What are Normal Symptoms to Experience During Breast Reduction Recovery

Medical References about Breast Reduction

• Breast Reduction Surgery – Mayo Clinic
• Breast Reduction Surgery: Everything You Need to Know – Medical News Today
• Breast Reduction Surgery – WebMD
• Breast Reduction – Cleveland Clinic
• Breast Reduction – NCBI