Does health insurance cover breast reductions?
If you’re about to go under the knife for breast reduction surgery, it’s essential to know whether your private health fund will help cover the cost of the procedure. Hospital cover policies cover surgical and accommodation costs for a wide range of procedures, but they will only pay a benefit for breast reduction surgery that is medically necessary, not for surgery conducted for cosmetic purposes.
Let’s take a closer look at what breast reduction surgery involves and how you can make a private health insurance claim.
What cover is available through private health insurance?
Private health insurance hospital cover is available in a range of levels to suit the cover needs and budgets of different people: public hospital cover, basic hospital cover, medium hospital cover and top hospital cover. While the exact list of treatments and procedures covered by these policies differ between funds, you will need a top or possibly mid-level policy in order to receive a benefit for breast reduction surgery.
However, in order to receive cover for the procedure, Medicare will need to deem it medically necessary. Breast reduction surgery conducted for purely cosmetic purposes isn’t covered by your health fund. There are also some funds that don’t offer any cover for breast reduction surgery.
You’ll need to check the specific terms and conditions of your health insurance policy to find out whether it’s possible to receive cover for the cost of the procedure. Your doctor will also need to provide information to support your claim and your eligibility for cover could depend on factors such as the amount of breast tissue to be removed.
Finally, it’s worth pointing out that any health problem that needs to be alleviated by breast reduction surgery will likely be classed as a pre-existing condition by your health fund, so you will need to serve a 12-month waiting period before you will be eligible to receive any benefits.
Signs that a breast reduction might be right for you
Medical reasons for breast reduction surgery include:
- Back pain and backaches
- Neck pain
- Shoulder pain
- Migraine headaches
- Shortness of breath
- Numbness in the hands and fingers
- Skin irritations
If you suffer from any of the above symptoms, breast reduction surgery could be beneficial for you.
However, the procedure does come with a number of risks attached and it’s important that you’re aware of them before going under the knife.
How much does breast reduction surgery cost?
The cost of a breast reduction procedure varies according to the surgeon you choose and the hospital where the surgery is performed. You’ll need to consider the surgeon’s fees, anaesthetist's costs and hospital accommodation costs when calculating the total bill for the procedure, but the overall cost could be around $7,000.
If the procedure is medically necessary, Medicare will pay a benefit to cover some of the cost. For example, reduction mammaplasty with surgical repositioning of the nipple is benefit number 45520 on the Medicare Benefits Schedule (MBS), with a maximum benefit of $675.35 paid per breast.
What’s involved in breast reduction surgery?
Breast reduction surgery, which is also commonly referred to as reduction mammaplasty, involves cutting and removing excess fat and glandular tissue from the breast, repositioning the nipple and areola higher on the breast and removing the excess skin. This makes the breasts smaller and lighter. The aim of the surgery is to produce breasts of a size and shape that are in proportion to the rest of the patient’s body.
However, it’s worth pointing out that it is recommended that you wait until your breasts are fully developed and childbirth and breastfeeding have been completed before undergoing the procedure. Your ability to breastfeed following breast reduction surgery may be harmed and changes to your breasts while pregnant can also alter the results of previously completed surgery.
Making a claim
If you’re planning on undergoing breast reduction surgery and need to know whether you’ll be covered, you’ll first need to find out whether the procedure will be deemed medically necessary by Medicare and therefore eligible for a benefit.
You will also need to provide details of the procedure to your health fund to determine whether or not you are eligible for cover. This usually involves filling out a medical estimate form with information on your surgeon, anaesthetist, procedure (including MBS item numbers) and the hospital where you will be treated. Your fund will then be able to tell you whether or not you will be covered and to what level.
Frequently asked questions about breast reductions