Is Breast Reduction Covered by Medicare?

If you’re carrying the daily weight of overly large breasts, like the persistent back pain, grooved shoulders, or rashes beneath the breast fold, you’ve probably considered breast reduction surgery. But the cost of the procedure and the uncertainty about whether Medicare covers any of it might be keeping you from moving forward.

The reality is that Medicare rebates for breast reductions are available, but only when your procedure meets specific clinical criteria set out in the Medicare Benefits Schedule (MBS).

Here’s what is and isn’t covered, and how to know if you meet the criteria.

Key Takeaways

• Medicare may rebate part of a breast reduction when it’s classified as medically necessary.
• The main MBS item numbers for female breast reduction are 45520, 45522 and 45523, each covering different clinical scenarios.
• You need documented symptoms (neck, shoulder or back pain), a referral from your GP, and photographic evidence in your patient notes.
• Medicare covers a portion of the surgeon’s and anaesthetist’s fees. It does not cover hospital accommodation.
• Eligibility is confirmed at consultation, not before. Your surgeon assesses whether your symptoms and anatomy satisfy the MBS criteria.

Does Medicare Cover Breast Reduction Surgery?

Medicare covers reduction mammaplasty when the procedure is performed to relieve a genuine medical problem rather than solely to change appearance. So when patients ask, “Does Medicare cover breast reduction surgery?” The honest answer is: it depends on the clinical picture.

The three relevant MBS item numbers for female patients are:

• Item 45523: Reduction mammaplasty (bilateral) with surgical repositioning of the nipple, for patients with macromastia who are experiencing pain in the neck or shoulder regionand not with the insertion of any prosthesis. The current Schedule Fee is $1,575.75, with a 75% benefit of $1,181.85.
• Item 45520: Reduction mammaplasty (unilateral) with nipple repositioning, in the context of breast cancer or a developmental breast abnormality.
• Item 45522: Reduction mammaplasty (unilateral) without nipple repositioning, excluding gynaecomastia and not involving a prosthesis.

For male patients, gynaecomastia surgery sits under separate item numbers (31525 unilateral, 31526 bilateral).

Medicare for Breast Reduction: The Criteria You Need to Meet

Medicare for breast reduction isn’t automatic. Under the MBS rules for item 45523, you generally need to demonstrate:

• Macromastia (breasts that are disproportionately large for your frame).
• Persistent neck, shoulder or back pain directly attributable to breast weight, typically documented over six months or more.
• Failed conservative measures – things like supportive bras, physiotherapy or weight management haven’t resolved symptoms.
• Photographic evidence included in your patient notes before surgery.
• A GP referral to a specialist plastic or breast surgeon.

Associated symptoms your surgeon will ask about include shoulder grooving from bra straps, chronic intertrigo (skin irritation under the breast), postural changes, headaches, and restriction in physical activity.

Mammaplasty Medicare Rebates: What You’ll Receive

Medicare rebates for Mammaplasty cover a portion (not all) of the surgeon’s and anaesthetist’s professional fees. The Medicare benefit is 75% of the Schedule Fee.

Your surgeon’s actual fee will usually be higher than the Schedule Fee, because the MBS amount hasn’t kept pace with the real cost of delivering safe, specialist surgical care. The difference between what your surgeon charges and what Medicare rebates is your out-of-pocket “gap”.

What Medicare for mammaplasty does not cover:

• Hospital fees (theatre, bed, nursing) – these are funded by private health insurance if you hold appropriate hospital cover with plastic and reconstructive surgery included (usually Gold-tier), or paid privately if you don’t.
• Post-surgical garments and some follow-up appointments.
• Procedures performed for purely cosmetic reasons, or where criteria aren’t met.

How To Work Out Where You Sit

At your consultation with a surgeon, eligibility is assessed directly. They’ll review your history, examine your symptoms, photograph what’s clinically needed for your file, and confirm whether one of the reduction mammaplasty item numbers applies to your case. You’ll leave with a written quote showing the Medicare rebate, private health contribution (if applicable), and your expected out-of-pocket cost.

If persistent pain and discomfort from breast size is affecting your daily life, book a consultation at BB Clinic on (02) 9819 7449 or via our contact page. Dr Yunaev will assess your suitability for a Medicare-rebated breast reduction surgery and walk you through exactly what it means for your costs, recovery and outcome.

If Medicare eligibility isn’t clear-cut, we’ll tell you honestly. Some patients sit on the borderline, and we’d rather you decide with the full picture than be surprised later.