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Breast reduction surgery health insurance

Breast reduction surgery is partially covered by Medicare and may be covered by private health insurance.

Many insurers will cover your breast reduction surgery if your referring doctor says it's necessary for your well-being. For example, if you have backaches, neck pain or migraines.

Breast reduction surgery is usually included in top-tier policies, but you may find it included in some mid-tier policies too.

Is breast reduction surgery covered by health insurance?

Some health insurance policies include a benefit for breast reduction surgery if it's medically necessary. 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.

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.

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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.

Finder survey: Which conditions have Australians made a hospital claim for?

ResponseFemale
Breast surgery1.72%
Source: Finder survey by Pure Profile of 1006 Australians, December 2023

How much does a breast reduction cost?

The overall cost of breast reduction surgery can be around $7,000, but it does depend. 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.

Is a breast reduction covered under Medicare?

If a breast reduction 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. However, with the procedure often costing $7,000 or more, Medicare definitely won't cover the entire bill.

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.

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