Will Medicare Cover My Gynaecomastia Surgery?

Dr Michael Kernohan MBBS, MSc, BDS, MRCS, FDSRCS, FRCS(Plast), FRACS (Plast

Medicare Coverage for Gynaecomastia Surgery in Australia

Gynaecomastia, a condition marked by the enlargement of breast tissue in males, is a topic that often raises many questions and concerns. This condition, while not widely discussed, affects a significant number of men at various stages of their lives. The reasons behind its development can range from hormonal imbalances to side effects of certain medications, and in some cases, it might not be clear why it has occurred at all. The physical changes brought about by gynaecomastia can be quite noticeable, and for many, this leads to a search for effective treatment options. Among these treatment options, surgery is one that many consider. However, the decision to undergo surgical intervention is not one to be taken lightly. It involves a variety of factors including the potential risks and benefits, the recovery process, and, notably, the financial implications. In Australia, one key question often arises in this context: Does Medicare cover gynaecomastia surgery? This question is particularly pertinent given that medical procedures can be costly, and understanding the extent of Medicare coverage is essential for anyone considering this option.

In this blog, Sydney Specialist Plastic Surgeon Dr Michael Kernohan aims to provide more information to help you navigate through the complexities of Medicare’s policies and procedures. The information provided here seeks to answer your most pressing questions and provide clarity on a subject that can often seem filled with uncertainties.

Download Dr Kernohan’s Male Breast Reduction Guide

Make Breast Reduction Guide
Make Breast Reduction Guide
  • This field is for validation purposes and should be left unchanged.

What is Gynaecomastia?

Gynaecomastia is a condition characterised by the enlargement of breast tissue in males. It’s essential to understand not only the physical attributes of this condition but also the broader impacts it may have on one’s life. This condition is relatively common, yet it often remains shrouded in a lack of awareness and understanding.

Firstly, let’s clarify what gynaecomastia is. It’s not simply a case of excess fat from weight gain, but a specific increase in glandular breast tissue. This enlargement can occur in one or both breasts and isn’t necessarily uniform. Several factors can contribute to the development of gynaecomastia, including hormonal imbalances, particularly an imbalance between oestrogen and testosterone. This imbalance can be triggered by various conditions such as puberty, ageing, or even certain medications and medical conditions like liver disease or hormone treatments.

The physical impact of gynaecomastia varies from person to person. For some, it might be a small, barely noticeable change, while for others, the growth can be significant. This physical change, however, can lead to discomfort. It may cause tenderness in the breast area, and in some cases, this can be accompanied by pain. The enlargement of breast tissue can also make physical activities or certain forms of exercise uncomfortable or awkward, leading to a change in lifestyle or a reduction in physical activity.

Medicare Coverage

Medicare Australia represents a fundamental aspect of the healthcare system in Australia, playing a pivotal role in ensuring that Australian citizens and permanent residents have access to affordable healthcare. Established with the intent to make healthcare accessible and affordable, Medicare Australia is a taxpayer-funded scheme. It covers a significant portion of healthcare costs, making it easier for individuals to access necessary medical care without facing prohibitive expenses. This system is designed to support you, ensuring that healthcare is not a privilege but a right available to all, regardless of their financial situation.

In terms of surgeries and medical procedures, Medicare’s coverage is substantial but with certain limitations. It generally covers surgeries and procedures that are deemed medically necessary. This means the surgery must be required to treat or diagnose a medical condition, rather than for cosmetic reasons. Examples of covered procedures include:

  • Surgical interventions for injuries or illnesses
  • Diagnostic procedures like X-rays and blood tests
  • Specific eye surgeries, such as cataract removal
  • Obstetric procedures, including childbirth and related care
  • Some orthopaedic surgeries, like hip replacements

The coverage for each procedure is determined based on a set of criteria that assess the necessity and effectiveness of the treatment. This is to ensure that the funds are used responsibly, prioritising treatments that offer significant health benefits. It is important to note that while Medicare covers a portion of the costs, there will still be out-of-pocket expenses, depending on the specific treatment and your surgeon.

Medicare Coverage for Gynaecomastia Surgery

Medicare Australia’s coverage for gynaecomastia surgery is a subject that necessitates a detailed examination, as it involves navigating a complex framework of medical policies and criteria. The key question you might be asking is: Does Medicare Australia provide coverage for gynaecomastia surgery? The answer to this is not entirely straightforward and hinges on various factors and conditions.

Before anything else, it’s important to understand that Medicare categorises surgeries into different types, primarily differentiating between cosmetic and reconstructive procedures. Cosmetic surgery, generally performed to enhance appearance, is not typically covered by Medicare. In contrast, reconstructive surgery, which is performed to correct abnormalities caused by congenital defects, developmental abnormalities, trauma, infection, tumours, or disease, is more likely to be covered.

When it comes to gynaecomastia surgery, Medicare’s coverage is usually contingent on whether the surgery is deemed medically necessary. This determination is based on several criteria:

  • Severity of the condition: If gynaecomastia is causing significant physical discomfort or pain, the surgery might be classified as medically necessary
  • Duration of the condition: Chronic conditions that have persisted over time and have not responded to other treatments may be more likely to qualify for coverage
  • Impact on daily life: If gynaecomastia is severely impacting your daily activities or quality of life, this may be taken into account
  • Underlying causes: If the condition is linked to other medical issues or arises as a side effect of necessary medication, this might influence the decision

It is essential to consult with your surgeon to ascertain whether your specific case of gynaecomastia meets these criteria. Dr Kernohan can provide a detailed assessment and help in preparing the necessary documentation to submit a claim to Medicare for coverage consideration.

MBS Guidelines for Gynaecomastia Surgery

Medicare Australia’s coverage for gynaecomastia surgery is defined under the Medicare Benefits Schedule (MBS) Item 31525. This item covers mastectomy for gynaecomastia (unilateral), with or without liposuction (suction assisted lipolysis), under specific conditions. These conditions include:

  • The breast enlargement is not due to obesity and is not proportionate to body habitus
  • There must be sufficient photographic evidence demonstrating the clinical need for the service included in the patient notes

The criteria for obtaining Medicare coverage for gynaecomastia surgery are stringent, focusing on the medical necessity of the procedure. Some of the conditions that may qualify for coverage include moderate to severe chest pain leading to physical or functional impairment, persistent gynaecomastia despite cessation of medications known to cause it, and a documented primary cause of gynaecomastia being glandular breast tissue.

Importantly, Medicare only covers breast reduction surgery if it is deemed medically necessary. Cosmetic procedures are not covered. To claim the surgery on Medicare, a valid medical referral is required, meeting strict criteria.

In terms of costs, if you have a private health plan, it may reimburse you for some or all of the hospital fees, depending on your level of coverage. However, your surgeon fee is generally an out-of-pocket expense.

Alternative Funding Options

When considering gynaecomastia surgery, and if you find that Medicare Australia does not cover the procedure, it’s essential to explore alternative funding options. This exploration is important because, without Medicare support, the financial responsibility falls all on you. Here, we’ll look into several avenues that could potentially provide financial assistance for your surgery, out-of-pocket expenses, and various financial assistance programs.

Private Health Insurance

In Australia, most Private Health Insurers follow the lead of Medicare. If you do not meet the criteria for your medical procedure to be covered by Medicare, (ie. you do not have an item number), your Private Health Insurer will not cover you. Policies vary significantly between providers, and coverage for gynaecomastia surgery can depend on the type of policy you hold. Consider the following aspects:

  • Review your policy: Check the specifics of your private health insurance policy to understand what is covered. Some policies might include coverage for surgeries deemed medically necessary, which could potentially include gynaecomastia surgery
  • Pre-existing condition clauses: Be aware of any stipulations related to pre-existing conditions, as these can affect your eligibility for coverage
  • Waiting periods: Understand any waiting periods that might apply before you can claim benefits for certain types of surgery

Out-of-Pocket Expenses

Paying for the surgery out-of-pocket is another option, albeit one that requires careful financial planning. This involves funding the entire cost of the surgery yourself. Here are some considerations:

  • Savings: Utilising personal savings can be a straightforward method, but it’s important to consider the impact on your overall financial stability
  • Payment plans: Some clinics offer payment plans, allowing you to spread the cost over time
  • Loans: Personal loans from banks or financial institutions are another option, but be mindful of interest rates and repayment terms

Additional Considerations

When exploring these funding options, it’s important to approach the decision with a clear understanding of the associated costs and implications. Consider the following:

  • Long-term financial impact: Any decision, particularly those involving loans or using savings, should be weighed against your long-term financial health
  • Full cost of the procedure: Ensure you have a full understanding of the total cost, including any post-operative care or additional treatments that may be necessary
  • Consultation with financial advisors: If you’re unsure about the best path forward, consider consulting with a financial advisor for personalised advice

While the journey to fund gynaecomastia surgery can be challenging, especially without Medicare coverage, there are multiple avenues to explore. Whether it’s through out-of-pocket funding, or seeking assistance through various programs, each option has its considerations and potential benefits. It’s essential to conduct thorough research, understand the implications of each choice, and seek professional advice where necessary to make an informed decision that aligns with your medical needs and financial circumstances.

FAQs about Medicare Cover for Gynaecomastia Surgery

FAQs

How do I prove the medical necessity of my gynaecomastia surgery to Medicare?

  • Medicare requires documented evidence of medical necessity for gynaecomastia surgery coverage. This typically involves a detailed medical report from your surgeon or specialist, outlining the physical symptoms and how they impact your daily life, along with any relevant diagnostic tests.

What documentation is needed for Medicare to cover gynaecomastia surgery?

  • Apart from a detailed medical report, you may need to provide photographic evidence of your condition, results of relevant medical tests, and a record of any previous treatments attempted. This documentation helps establish the non-cosmetic nature of the surgery.

Can Medicare deny coverage for my gynaecomastia surgery?

  • Yes, Medicare can deny coverage if the surgery is deemed cosmetic or if there isn’t sufficient evidence to classify it as medically necessary. It’s important to ensure that all required documentation and evidence are provided to support the medical necessity of the procedure.

Are there any conditions under which Medicare will definitely cover gynaecomastia surgery?

  • Medicare coverage is more likely if the gynaecomastia causes significant pain, physical impairment, or is related to certain medical conditions. However, coverage is determined on a case-by-case basis, and meeting these conditions doesn’t guarantee approval.

If Medicare covers my surgery, will it cover all associated costs?

  • Medicare can cover a portion of the surgery costs, which can include some of the surgeon’s fee and some hospital costs. However, it will not cover all associated expenses, such as the full hospital stay, anaesthetist fees, and post-operative care.

Further Reading about Gynaecomastia Surgery with Sydney Plastic Surgeon Dr Michael Kernohan

Medical References about Gynaecomastia Surgery