Does Medicare Cover Reduction Mammoplasty (Breast Reduction)?

March 15, 2024

Reduction Mammoplasty (Breast reduction surgery) is a transformative procedure for many, offering significant relief from physical discomfort. Understanding the financial aspects of Reduction Mammoplasty, particularly Medicare coverage in Australia, is crucial for individuals considering this path. This article delves into the intricacies of Medicare’s coverage for reduction mammoplasty (breast reduction), providing clear insights for those navigating this journey.

Understanding Reduction Mammoplasty

Breast reduction surgery, or reduction mammoplasty, is more than a cosmetic procedure—it’s a medically recommended solution for individuals suffering from health issues associated with overly large breasts. These issues can include chronic back, neck, and shoulder pain, skin irritation beneath the breast fold, and other physical discomforts that impact daily life and psychological health. Recognising the medical necessity behind breast reduction helps frame Medicare’s approach to coverage, emphasising the distinction between elective cosmetic procedures and those deemed essential for a patient’s health.

Medicare Coverage Criteria: Will Medicare Cover Reduction Mammoplasty (Breast Reduction)?

The Australian Medicare system provides coverage for reduction mammoplasty (breast reduction surgery) under specific conditions, primarily focusing on the procedure’s medical necessity. Coverage is not universal but is available to those who meet Medicare’s defined criteria, which include:

  • Documented Medical Necessity: Patients must have a detailed medical history documenting the physical symptoms and health issues caused by large breasts. This documentation often includes reports from general practitioners, physiotherapists, or other specialists. 
  • Previous Alternative Treatments: Evidence of having pursued alternative non-surgical treatments to alleviate symptoms, such as physical therapy or weight management programs, without sufficient relief.
  • Consultation with a Specialist: A consultation with a plastic or reconstructive surgeon who can assess the medical necessity of the procedure and provide a professional recommendation for surgery.

Medicare’s coverage typically extends to a small portion of the surgeon’s fees and hospital costs associated with the surgery, identified by specific item numbers. It’s important for patients to understand that while Medicare can reduce the financial burden for those who meet the criteria, there will also  be out-of-pocket expenses involved.

Navigating the Process

For individuals considering reduction mammoplasty (breast reduction surgery) under Medicare, the process involves several key steps:

  • Initial Consultation: Start with a consultation with a specialist plastic or reconstructive surgeon who specialises in reduction mammoplasty (breast reduction). They will evaluate your condition, discuss potential benefits, and determine if you meet the criteria for Medicare coverage.
  • Gathering Documentation: Compile all relevant medical documentation that supports the necessity of reduction mammoplasty. This includes medical records, reports detailing unsuccessful alternative treatments, and any recommendations from healthcare professionals.
  • Medicare Pre-authorisation: With your surgeon’s assistance, submit a request for pre-authorisation to Medicare, including all necessary documentation to demonstrate the procedure’s medical necessity.
  • Understanding Financial Responsibilities: Discuss with your surgeon and Medicare the extent of coverage provided, including what costs will be covered and any out-of-pocket expenses.

Embracing Your Health and Wellbeing

Embarking on the path to reduction mammoplasty (breast reduction surgery) with Medicare’s support involves a thorough understanding of both the medical and administrative processes. At Shape Clinic, we’re committed to guiding you through every step, from initial consultation to post-operative care, ensuring you’re informed, prepared, and confident in your decision. 

If you’re considering reduction mammoplasty (breast reduction surgery) and seeking clarity on Medicare coverage, we encourage you to reach out to our friendly team for personalised advice and support.