Is Breast Augmentation Surgery Covered by Medicare?

Cosmetic breast augmentation is not covered by Medicare in Australia. The breast augmentation Medicare items exist for two situations only (surgery in the context of breast cancer, and correction of a developmental abnormality of the breast), and each carries criteria written directly into the item descriptor.

Below is what those items cover, the two-volume thresholds that decide eligibility, how the volume difference has to be measured and documented, and what the rebate is worth against the real cost of surgery.

Key Takeaways

• Two augmentation items sit on the schedule: 45524 (unilateral) and 45528 (bilateral). The criteria differ significantly.
• Item 45524 requires either breast cancer or a developmental abnormality with a measured volume difference of at least 20% in normally shaped breasts, or 10% in tubular breasts or breasts with abnormally high inframammary folds.
• Item 45528 carries no volume threshold. It requires developmental malformation of breast tissue (specifically excluding hypomastia), disease or trauma to the breast, or amastia from a congenital endocrine disorder.
• The volume difference must be demonstrated using a technique published in a peer-reviewed journal, and the volumes recorded in your case notes.
• From 1 July 2026, three new items (45070, 45071 and 45072) cover unilateral correction of a developmental breast abnormality.
• Rebates are partial. Item 45524 pays a $665.80 benefit; item 45528 pays $998.55. That is the surgeon’s fee only.

Does Medicare Cover Breast Augmentation for Cosmetic Reasons?

No. Services Australia’s assessing rules list breast implants among the procedures that attract no Medicare benefit when performed for cosmetic reasons, alongside face lifts, tummy tucks and liposuction.

Medicare pays benefits for clinically relevant services, which are services that are generally accepted by the profession as necessary for the appropriate treatment of a patient. Wanting fuller breast implants is not a clinical indication, and no item number describes it.

So the useful question isn’t really does Medicare cover breast augmentation as a procedure. It’s whether your own presentation matches the wording of a specific item.

The Breast Augmentation Medicare Items: 45524 and 45528

Item 45524: Unilateral Augmentation

Item 45524 covers augmentation mammaplasty on one breast, in the context of:

1. Breast cancer; or
2. Developmental abnormality of the breast, where there is a difference in breast volume, demonstrated by an appropriate volumetric measurement technique, of at least:
   • 20% in normally shaped breasts; or
   • 10% in tubular breasts or in breasts with abnormally high inframammary folds.

Which applies depends on the shape of the breasts, not on how uncomfortable the difference feels.

Item 45528: Bilateral Augmentation

Item 45528 works differently. It carries no volume threshold at all. Instead, it requires reconstructive surgery to be indicated because of:

• developmental malformation of breast tissue, excluding hypomastia; or
• disease of or trauma to the breast, other than trauma resulting from previous elective cosmetic surgery; or
• amastia secondary to a congenital endocrine disorder.

Plus, photographic or diagnostic imaging evidence of clinical need documented in the patient notes.

Hypomastia means naturally small breasts that developed without malformation. It is the single most common reason people seek augmentation, and the item rules it out by name. The bilateral breast augmentation Medicare pathway is built for malformation, disease and trauma, not for volume alone.

Both items involve inserting a prosthesis. Where the plan is breast augmentation using your own tissue rather than implants, explanatory note TN.8.294 directs that autologous fat grafting in the context of breast cancer or developmental disorders is claimed under items 45534 and 45535 instead.

How the Volume Difference Is Measured

Explanatory note TN.8.96 sets two requirements:

1. Volumetric measurement of the breasts is expected to be performed using a recognised technique published in a peer-reviewed journal article
2. Breast volumes and volume differences should be recorded in the patient case notes.

It is not enough for a surgeon to observe that one side is noticeably smaller. A specific method has to be used, and the numbers have to be written down. Techniques used in practice include 3D surface imaging, MRI-based volumetry, and validated anthropometric formulas. The note doesn’t mandate one, only that whichever is used has a published basis.

Both augmentation items also require photographic or diagnostic imaging evidence of clinical need in the notes. That requirement exists because these claims are auditable. The Department of Health, Disability and Ageing can ask a practitioner to produce the record afterwards, which is why careful assessment documents conservatively rather than rounding toward eligibility.

Ask at consultation how your volume difference will be measured and whether the figure will be recorded.

Tuberous Breasts and Medicare: Why the Threshold Drops to 10%

Tuberous breasts (also called tubular or constricted breasts) develop with a narrow base, a high inframammary fold, a herniated or enlarged areola, and limited lower pole tissue. The condition is developmental, not acquired.

Under the tuberous breasts Medicare criteria in item 45524, the required volume difference decreases from 20% to 10% when the breasts are tubular or carry abnormally high inframammary folds. The same halved threshold appears in the developmental breast abnormality items.

Tuberous breast correction rarely means an implant on its own. Constricted tissue usually needs releasing, the fold often needs lowering, and the areola may need reducing. Item 45060 covers single-stage correction of a developmental breast abnormality, either bilateral mastopexy for symmetrical tubular breasts, or surgery on both breasts combining implants (which must differ by at least 10% in volume), mastopexy or reduction. Items 45061 and 45062 cover the first and second stages, where a tissue expander is used first.

New From 1 July 2026: Items 45070, 45071 and 45072

Until this year, the developmental breast abnormality items only described surgery on both breasts. Someone with a one-sided developmental difference had no matching item.

That changed on 1 July 2026, when the Department introduced three new items as unilateral equivalents of 45060, 45061 and 45062.

Item 45070 covers single-stage correction involving surgery on one breast, where the correction involves either an implant with or without mastopexy, or reduction mammaplasty, and there is a volume difference with the other breast of at least 20% in normally shaped breasts or 10% in tubular breasts or breasts with abnormally high inframammary folds. Items 45071 and 45072 cover the two-stage unilateral pathway.

If you were told a few years ago that a one-sided correction had no item number, that advice is now outdated. This is relevant to anyone considering breast asymmetry correction where only one side needs surgery.

Medicare Breast Augmentation Rebates: What You Get Back

These figures are current on the schedule effective 1 July 2026.

The schedule fee is not what a specialist surgeon charges. Medicare pays 75% of the schedule fee for an admitted private patient, and a fund with hospital cover for that service pays at least the remaining 25%. Anything your surgeon charges above the schedule fee is your gap.

These items cover the surgeon’s fee alone. Anaesthesia, hospital accommodation, theatre time and the implants themselves are billed separately, which is why Medicare breast augmentation rebates offset a portion of the total rather than most of it. Our guide to breast augmentation cost breaks down each component.

And schedule fees are indexed every 1 July, so confirm the current amount close to your surgery date.

What Medicare Won’t Pay When Surgery Is Cosmetic

Where the surgery doesn’t attract a benefit, Services Australia’s rules confirm that benefits are also not payable for assistance at the operation, for administration of the anaesthetic, including the pre-operative examination, or for initial and subsequent consultations relating entirely to assessment or discussion of cosmetic services.

A consultation still attracts a benefit where it is a clinically relevant assessment of a symptomatic or structural complaint, and you hold a valid referral.

Private health insurance follows the same logic. A fund can only pay toward medical fees where a valid MBS item applies.

What to Bring to Your Consultation

Under the Medical Board of Australia’s cosmetic surgery guidelines, in effect since 1 July 2023, every patient needs a referral before cosmetic surgery. Preferably from their usual GP, and from a practitioner who doesn’t perform the procedure. For adults, a cooling-off period of at least seven days must pass after two consultations and signed informed consent. For patients under 18, that period is three months, with independent evaluation by a psychologist, psychiatrist or GP. Screening for body dysmorphic disorder is required for all cosmetic surgery patients.

Bring your GP referral, any previous imaging, a written note of symptoms and how long you’ve had them, and your health fund details, including the level of hospital cover and when it started.

If the items don’t apply to your situation, some patients look at early release of superannuation, which has its own strict eligibility rules administered by the ATO.

Getting Assessed in Sydney

Whether Medicare contributes to your augmentation depends on a documented clinical finding and a measured number, assessed against wording that leaves little room for interpretation. It has nothing to do with how much the difference bothers you.

If you’re weighing up breast augmentation Medicare eligibility, the only way to know where you stand is a proper assessment against the item wording.

At BB Clinic, Dr Michael Yunaev (FRACS, Specialist Breast and General Surgeon, 22+ years of surgical experience) assesses breast shape, symmetry and volume against the relevant item criteria at consultation, and sets out the total cost in writing before anything is booked.

Whether you’re considering tuberous breast correction, breast reconstruction after cancer, Medicare for breast implants, or wondering if you are eligible for breast augmentation with Medicare in Sydney, you’ll get a clear understanding of which items apply to you and which don’t.

Call (02) 9819 7449 or book a consultation at Potts Point, Bella Vista or Gledswood Hills.