Medicare in Australia is structured to provide support for procedures that are considered medically necessary, but this doesn’t always extend to surgery that’s classed as cosmetic.
When it comes to breast lift Medicare cover (this doesnt make sense?), it can be a little more complex. While the procedure is often viewed as cosmetic, it can sometimes be considered as a means to address more physical concerns.
Understanding how Medicare makes the distinction between cosmetic and medically necessary procedures can help you plan for the costs of your procedure ahead of time.
What are Medicare item numbers?
Medicare uses what are known as item numbers to determine whether a procedure is eligible for cover.
There is an item number – 45558
Correction of bilateral BREAST PTOSIS by mastopexy, if:
(a) at least two‑thirds of the breast tissue, including the nipple, lies inferior to the inframammary fold where the nipple is located at
the most dependent, inferior part of the breast contour; and
(b) photographic evidence (including anterior, left lateral and right lateral views), with a marker at the level of the inframammary
fold, demonstrating the clinical need for this service, is documented in the patient notes.
Applicable only once per lifetime, other than a service associated with a service to which item EO512, EO513 or EO514 applies on
the same side
NEED TO HIGHLIGHT HOW THIS IS ELIGBLE
These numbers are part of the Medicare Benefits Schedule (MBS), which outlines the conditions and requirements attached to a wide range of surgeries. A breast lift, medically referred to as a mastopexy, will not usually attract an item number if it’s being performed for cosmetic reasons alone.
That being said, there are certain scenarios where a breast lift can be considered reconstructive, and in these cases, Medicare may apply.
To qualify, the surgery needs to meet very specific criteria set out by the MBS, and surgeons are required to document these criteria carefully. This documentation becomes part of the application for a Medicare rebate.
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When may a patient be eligible for breast lift Medicare cover?
While the majority of mastopexy procedures are not covered, there are some defined circumstances where cover may be possible.
A common situation is when there has been a significant physical change to the breasts due to factors outside of normal ageing, such as weight loss or pregnancy. If this change results in physical symptoms like persistent skin irritation beneath the breast fold, chronic rashes, or difficulties with posture, there may be grounds for the procedure to be classified differently.
Medicare generally looks for evidence that the surgery is addressing a functional problem rather than simply changing the shape or position of the breast. For example, if excess skin and breast tissue are causing ongoing skin breakdown or infections that haven’t responded to non-surgical treatments, this could support the case for Medicare cover.
How is reconstructive surgery defined?
Reconstructive surgery is distinct from cosmetic surgery in Medicare’s terms.
Cosmetic surgery is performed to change physical appearance, while reconstructive surgery is linked to addressing abnormalities, congenital conditions, or physical changes that are causing functional concerns.
A breast lift may fall into the reconstructive category if it’s performed after significant weight loss or as part of treatment for another condition, such as breast reduction or correction of breast asymmetry after trauma or earlier surgery.
However, it’s important that patients know these classifications are not automatically applied. Each case is assessed individually, and the surgeon must be able to demonstrate how the procedure meets the requirements of a Medicare item number. Without this, the procedure will be considered cosmetic and therefore not be eligible for cover.
What about out-of-pocket costs?
Even in cases where Medicare does apply, patients should be prepared for out-of-pocket costs.
A Medicare rebate will usually only cover a portion of the surgeon’s fee, along with part of the anaesthetic and hospital costs. The surgeons’ fees will exceed the rebate, which means there is still a gap that the patient will need to pay.
If a private health fund is able to help, this may reduce the out-of-pocket costs further, but cover will depend on the level of insurance held and whether the procedure has been approved under a Medicare item number. Without an item number, private health insurance will not typically be able to contribute, as the insurer relies on Medicare’s classification to determine eligibility.
What kind of documents and evidence will be needed?
Clear documentation is essential for Medicare to be able to provide cover.
Surgeons are often required to provide photographs, medical reports, and clinical notes that outline the physical problems caused by breast position or skin changes.
For example, if a patient experiences chronic intertrigo (a skin condition caused by friction and moisture beneath the breast fold), evidence of repeated medical treatment for this condition may be needed before Medicare recognises the surgery as necessary.
The documentation and evidence is assessed by Medicare to confirm that the case meets the strict conditions attached to the relevant item number. Without thorough records, approval may not be granted, even if the patient does experience physical symptoms.
What can I expect during a consultation with my surgeon?
When discussing breast lift surgery with a surgeon, patients can ask whether their situation may fall under a Medicare item number.
During the consultation, the surgeon will assess the physical changes, review any associated health issues, and advise whether the criteria might be met. If it seems possible, they will usually begin gathering the necessary documentation at this stage.
The consultation also provides an opportunity to discuss the likely costs, including what Medicare may cover, how private health insurance might contribute, and what the out-of-pocket expenses will look like. Transparency is important so that patients can make informed decisions about proceeding with the surgery, as well as prepare for the costs of the procedure.
Why choose Specialist Plastic and Reconstructive Surgeon A/Prof Bish Soliman?
A breast lift should always be performed by a qualified surgeon with experience in performing the procedure. Based in
Sydney, not only does A/Prof Bish Soliman have experience in performing breast lifts, but he also has specialised experience in performing reconstructive procedures.
As a Specialist Plastic and Reconstructive Surgeon, A/Prof Bish has undergone extensive training to specialise in complex microsurgical reconstruction, as well as aesthetic surgery of the breast, body and face.
Given the complexity of Medicare criteria, it’s important that patients seek out a surgeon who can clearly explain the process and what is realistically covered. Choosing an experienced surgeon will help you get the clearest picture of whether or not
your procedure might fall under Medicare cover eligibility and what your total costs are likely to be.
To discuss your surgical needs with A/Prof Bish, please get in touch with our team to schedule your confidential consultation in Sydney.
