Medicare Criteria for Breast Lift Surgery in Sydney
In Australia, Medicare represents the foundation of the healthcare system, providing access to a wide range of health services for all Australian citizens and permanent residents. This public health insurance scheme is designed to ensure affordable, or in some cases, no-cost access to necessary healthcare.
Being aware of Medicare’s stance on cosmetic surgery, including procedures like breast lift, is essential for anyone considering these options. Generally, Medicare in Australia has a specific perspective on what constitutes necessary medical treatment versus elective cosmetic procedures. The key is in distinguishing between medically necessary procedures and those performed for aesthetic reasons.
Cosmetic surgery, in the context of Medicare, refers to operations and procedures that revise or change the appearance of normal bodily features to enhance or improve one’s appearance. These include surgeries like breast surgery, liposuction, and facial cosmetic surgery. Medicare’s policy on such procedures is quite clear:
Cosmetic surgery for purely aesthetic reasons is not covered by Medicare
Only procedures considered clinically necessary for the improvement of a health condition are eligible for Medicare benefits
For instance, a breast lift, or mastopexy, involves reshaping and elevating the breasts. While it’s often sought for its aesthetic benefits, there are scenarios where this procedure might be considered medically necessary. If a breast lift is needed to rectify physical issues or is part of a reconstruction following mastectomy, it may fall under the category of surgeries covered by Medicare.
However, it is important to note that the eligibility for Medicare benefits in these cases is not automatic. The procedure must be proven as essential for the treatment of a diagnosable condition. For example, if the breast condition is causing physical pain, skin conditions, or other medical problems, and a breast lift is the recommended treatment, then it might be covered.
In such cases, the following aspects are vital:
A referral from a general practitioner is required to justify the medical necessity of the procedure
Detailed documentation illustrating the medical reasons for the surgery
Patients considering a breast lift, or any cosmetic procedure, should have a comprehensive discussion with their plastic surgeon. This conversation should include an exploration of the reasons for the surgery, its necessity from a medical standpoint, and the likelihood of Medicare coverage.
Additionally, it is wise to consider other funding options to cover costs that Medicare may not. Understanding your private health insurance policy’s specifics and the criteria for coverage under Medicare is key to making an informed decision about undergoing a cosmetic procedure.
Breast lift surgery, medically known as mastopexy, is a procedure undertaken to change the shape of the breasts. During this surgery, excess skin is removed and breast tissue is reshaped to raise the breasts. You might be considering this surgery for a variety of reasons, which can include:
Changes in the breasts due to ageing: As time passes, it’s natural for the shape of the breasts to change. This is often due to a loss of skin elasticity and the effects of gravity
Alterations following pregnancy and breastfeeding: These life stages can lead to significant changes in the size and shape of the breasts, often leading to sagging or a loss of firmness
Weight fluctuations: Significant changes in weight can affect the size and shape of the breasts, sometimes resulting in a desire to restore a previous appearance
Improving symmetry: In some cases, there may be a noticeable asymmetry in the breasts, and a breast lift can help in achieving a more balanced look
It’s important to have realistic expectations about what this surgery can achieve. While a breast lift can alter the contour of your breasts, it won’t significantly change their size. If you’re looking for a change in breast size, you might consider combining a breast lift with breast augmentation or reduction.
Before deciding on breast lift surgery, it’s essential to discuss your expectations and any concerns with Dr Michael Kernohan. He will be able to provide advice tailored to your particular situation, including:
Assessing your general health to ensure you’re a suitable candidate for surgery
Discussing the potential outcomes and any risks or complications associated with the procedure
Explaining the surgical technique and what you can expect during recovery
It’s also vital to understand that the results might not be permanent. Factors such as ageing, weight fluctuations, and hormonal changes can affect the longevity of the results.
When considering a breast lift, bear in mind the following aspects:
Recovery time varies from person to person, but typically, it’s recommended to take it easy for a few weeks post-surgery
You may need to wear a support bra or compression garments to support healing and reshape the breasts during the recovery period
As with any surgery, there are risks involved, including scarring, changes in breast or nipple sensation, and potential complications related to anaesthesia
Download Dr Kernohan’s Cosmetic Breast Ultimate Guide
Guide Cosmetic Breast Surgery
Criteria for Medicare Coverage
In Australia, understanding the criteria for Medicare coverage is essential if you’re considering a surgical procedure like a breast lift. Medicare, the country’s public health insurance scheme, covers a range of medical treatments, but it’s important to know that not all procedures, especially those deemed cosmetic, are included. Let’s explore the general criteria for surgeries covered by Medicare and how these apply specifically to breast lift surgeries.
Medicare covers surgeries that are medically necessary. This includes procedures that are:
Essential for the diagnosis, cure, mitigation, treatment, or prevention of disease
Necessary to improve or maintain the function of a body part
Necessary to treat an injury, illness, or symptoms
In line with the standards of medical practice in Australia
For breast lift surgeries, or mastopexy, the situation is more nuanced. Medicare’s coverage for breast lifts hinges on whether the surgery is considered cosmetic or reconstructive:
Reconstructive surgery: If a breast lift is required as part of reconstructive surgery, for instance after a mastectomy due to breast cancer, Medicare may cover it. Such procedures are generally recognised as medically necessary because they are integral to a patient’s recovery and overall health
Cosmetic surgery: On the other hand, if a breast lift is purely for aesthetic improvement, it’s unlikely to be covered by Medicare. Cosmetic procedures are usually elective surgeries that are not considered medically necessary
It’s important to understand the specifics of Medicare coverage when considering a breast lift. If you’re exploring this surgery for cosmetic reasons, you should be prepared for the possibility that the costs will not be covered by Medicare. But if the procedure is part of a medically necessary reconstructive process, there’s a higher likelihood of coverage.
The key steps to determine Medicare coverage for your breast lift surgery include:
Consultation with a medical professional: A detailed evaluation by a general practitioner and a qualified surgeon can help establish whether your procedure could be considered medically necessary
Documentation: Proper documentation explaining the medical reasons for the surgery is crucial. This may include medical records, reports on physical symptoms, and a detailed treatment plan
When planning for a breast lift surgery, it’s important to have realistic expectations regarding Medicare coverage. Understanding the criteria and consulting with medical professionals will provide clarity on whether your procedure is likely to be covered. Additionally, exploring other financial options, such as private health insurance or personal savings, might be necessary to cover the costs of the procedure if it falls outside Medicare’s coverage.
Medicare Item Numbers 45558 and 45556 for Breast Lift Surgery
In Australia, Medicare uses specific item numbers to categorise medical procedures. For breast lift surgery, the relevant item numbers are 45558 and 45556. These numbers are critical for patients seeking coverage, as they indicate that the surgery is not just for altering appearance but is medically necessary. Here’s what you need to know about these item numbers:
Item Number 45558: Item 45558 applies where correction of breast ptosis is indicated because at least two-thirds of the breast tissue, including the nipple, lies inferior to the infra-mammary fold where the nipple is located at the most dependent, inferior part of the breast contour. This item number can’t be used with the insertion of any prosthesis
Item Number 45556: This number is used for the correction of unilateral breast ptosis, in the context of breast cancer or developmental abnormality, if photographic evidence (including anterior, left lateral and right lateral views) and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes
Getting Medicare Coverage for Breast Lift Surgery
Obtaining Medicare coverage for your breast lift surgery involves several important steps. It’s not simply a matter of applying; you must provide adequate proof that the surgery is medically necessary. Here’s how you can navigate this process:
Consultation with a Surgeon: The first step is to consult with a plastic surgeon who is experienced in breast surgeries. During this consultation, your surgeon will assess your condition and determine if your case aligns with the criteria set out under the Medicare item numbers
Medical Necessity Documentation: If your surgeon agrees that your surgery is medically necessary, they will document this. The documentation (including photographs) should explain how your condition aligns with the Medicare item numbers and why the surgery is essential for your health
Additional Financing Options
When considering breast lift surgery in Australia, exploring additional insurance options becomes crucial, especially if Medicare does not cover your procedure. Supplemental insurance and private insurance considerations can offer alternative avenues for funding your surgery. Here’s what you need to know:
Private Insurance
Private Health Insurance: Many Australians opt for private health insurance in Australia. However, most Private Health insurance in Australia will not cover a procedure that does not have an item number (ie. procedures that are considered cosmetic are not covered). If Medicare won’t cover it, mostly likely neither will your health fund.
Checking Specifics for Surgery Coverage: Before proceeding, confirm with your insurance provider whether breast lift surgery is covered under your policy, and to what extent
Reviewing Waiting Periods: Be aware of any waiting periods that may apply before you can claim benefits for certain procedures
Costs to Consider Without Medicare Coverage
If you’re going ahead with breast lift surgery without Medicare coverage, understanding and planning for the associated costs is essential. Here’s a guide to help you navigate this aspect:
Estimating the Cost of Breast Lift Surgery
Surgeon’s Fees: This will likely be the most significant portion of the cost. Surgeon’s fees can vary widely based on their experience, the complexity of the surgery, and geographic location
Hospital and Anaesthesia Costs: If the surgery is not covered by Medicare or insurance, you’ll also need to pay for the hospital stay and anaesthesia
Additional Medical Expenses: This includes post-surgery garments, medication, and any follow-up consultations or treatments
Financial Planning and Savings Options
Saving for the Procedure: If you’re considering a breast lift, it may be wise to start saving in advance. Create a dedicated savings plan for the surgery
Payment Plans and Medical Loans: Some clinics offer payment plans to spread the cost over time. Alternatively, medical loans can be an option, though it’s important to carefully consider the terms and interest rates
Considering Other Financial Sources: Explore if you can use funds from a health savings account (if applicable) or if family assistance is an option
Does Medicare in Australia cover breast lift surgery?
Medicare typically covers surgical procedures that are medically necessary, rather than those performed for cosmetic reasons. For breast lift surgery to be covered, it must be deemed essential for treating a medical condition or for reconstructive purposes, such as post-mastectomy reconstruction.
What are the requirements for a breast lift surgery to be considered medically necessary?
For a breast lift surgery to be deemed medically necessary, there must be clear medical reasons such as correcting asymmetry caused by congenital defects, post-surgical reconstruction, or alleviating physical discomfort due to the condition of the breasts. Documentation from a qualified plastic surgeon, detailing the medical necessity, is required for Medicare consideration.
Can I get Medicare coverage for a breast lift after significant weight loss or pregnancy?
Medicare coverage for a breast lift following significant weight loss or pregnancy depends on individual circumstances. If the surgery is required to address medical issues such as skin infections or physical discomfort caused by excess skin, it may be covered. However, if the surgery is primarily for cosmetic improvement, it is unlikely to be covered.
What Medicare item numbers are relevant for breast lift surgery?
Medicare item numbers 45558 and 45556 are often referenced in relation to breast lift surgeries. These item numbers are used for procedures that are considered reconstructive and medically necessary, rather than purely cosmetic.
If Medicare does not cover my breast lift surgery, what are my other options?
If Medicare does not cover your breast lift surgery, you might consider personal savings, payment plans offered by your surgeon, or medical loans. It’s important to thoroughly research and understand all potential costs and coverage options before proceeding with the surgery.
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Dr Michael Kernohan MBBS, MSc, BDS, MRCS, FDSRCS, FRCS(Plast), FRACS (Plast
Dr Michael Kernohan is a highly experienced Plastic, Reconstructive and Cosmetic Surgeon, fully qualified in both Australia and the UK. He has had extensive training, holding qualifications in both dentistry and medicine. His training path has taken him around the world acquiring skills from some of the world’s best surgeons.