Breast reduction surgery health insurance

How much does breast reduction surgery cost?

The cost of a breast reduction varies depending on the type and reason for the surgery. In the private system, without insurance, a unilateral breast reduction $10,000. This surgery is normally done on a healthy breast after a cancer is removed from the other breast, to even them up. A bilateral breast reduction can cost closer to $15,000 - these surgeries are done for a range of other medical reasons.

If you have private hospital insurance that covers breast surgery, you'll be able to get some of that private surgery covered. According to Medical Costs Finder, the typical out of pocket payment is around $1,000 for unilateral procedures, but around $8,400 for bilateral procedures.

Does Medicare cover breast reduction surgery?

Medicare will cover medical breast reduction surgery in a public hospital, so you won't have anything to pay out of your own pocket. Unfortunately, breast reduction is often categorised in one of the lower priority surgery categories, so you could be waiting over a year for surgery. The medical reasons for your surgery could affect your prioritisation category.

How does private health insurance cover breast reduction?

Breast surgery is covered under Bronze tier hospital policies. If you are covered and need surgery it will cover some, but not all, or your treatment costs. Exactly how much you'll have to pay for your breast reduction will depend on the reason for the surgery, whether or not it is unilateral or bilateral, as well as your private health fund's gap payment arrangements.

To reduce your our of pocket costs, you should call your health fund before the surgery is booked in. This will let them explain how the gap payment works, and if there are any ways you can reduce the gap, such as getting the work done at one of their agreement hospitals.

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.

It’s also worth noting 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:

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.

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.

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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

• How does Medicare determine if a breast reduction is medically necessary?

  For a breast reduction to be deemed medically necessary by Medicare, specific criteria must be met. This typically involves the removal of a certain amount of glandular tissue from each breast, usually 500 grams or more, and the presence of documented symptoms such as chronic back pain, neck pain or shoulder pain. Your surgeon will need to provide evidence supporting the medical necessity by using specific Medicare Benefits Schedule (MBS) item numbers for the procedure.

• What is the typical recovery time after breast reduction surgery?

  The initial recovery period often involves a hospital stay of one to three days. Most patients can return to light activities and non physical work within two to three weeks. Strenuous exercise, heavy lifting and other physical activities should be avoided for six to eight weeks to allow for proper healing. Swelling and bruising are common and can take several months to fully subside.

• What are the potential risks and complications of breast reduction surgery?

  As with any surgery, breast reduction carries potential risks. These can include infection, bleeding, adverse reactions to anaesthesia and changes in breast or nipple sensation which may be temporary or permanent. Other possible complications include asymmetry, difficulty breastfeeding, fat necrosis or the need for revision surgery.

• Can I choose my own surgeon and hospital for a private breast reduction?

  Yes, if you have private health insurance you generally have the freedom to choose your surgeon and hospital. However, your choice can impact your out of pocket costs. Health funds have preferred provider agreements with certain hospitals and surgeons which may result in lower gap payments. It's best to discuss fees with your chosen surgeon and anaesthetist and to contact your health fund before booking your surgery.

• Does private health insurance cover revision surgery if I have complications or am not satisfied with the initial outcome?

  Private health insurance typically covers revision surgery that is medically necessary due to complications from the initial procedure such as infection, significant asymmetry or persistent pain related to the original medical condition. However, if the revision is purely for cosmetic reasons or dissatisfaction with the aesthetic outcome, it is generally not covered.

• How do health funds differentiate between a cosmetic and a medically necessary breast reduction?

  Health funds differentiate between cosmetic and medically necessary breast reductions primarily based on the criteria for Medicare Benefits Schedule (MBS) item numbers. A procedure is considered medically necessary when it addresses significant physical symptoms like severe back pain, neck pain or shoulder pain and involves the removal of a substantial amount of tissue. Cosmetic surgery, by contrast, is performed solely to improve appearance and does not meet these medical criteria, therefore it is not covered by health insurance.

To make sure you get accurate and helpful information, this guide has been edited by Peta Taylor as part of our fact-checking process.

Written by

Tim Bennett

Insurance expert

A seasoned journalist with over 10 years of experience in news, politics and finance reporting, Tim has previously held roles at the ABC, SBS and Fairfax Media. Tim’s expert insights have been quoted in The Australian, The Daily Telegraph, The Courier Mail and more. He regularly appears on TV and radio, and has been interviewed on 7 News, Sunrise, SBS News, ABC Local, 3AW and 5AA. Tim is passionate about simplifying complex insurance topics for Australian consumers. He holds a Bachelor of Arts (Politics) from Macquarie University and a Tier 1 General Insurance (General Advice) certification, which meets the requirements of ASIC Regulatory Guide 146 (RG146). If you’re interested in a media interview with Tim, please reach out to our PR team at aupr@finder.com. See full bio

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