Here at the Breast and Body clinic, we get a lot of queries about the benefits provided by Medicare when it comes to breast reduction surgery, or reduction mammoplasty. The reason why this is asked so much is that in some cases it may be medically necessary to undergo the procedure to treat situations like macromastia or breast hypertrophy which are having adverse effects on a woman’s health.
These conditions can cause headaches, back and neck pain, along with skin problems. There are Medicare benefits available in these cases, but there are two conditions required to ensure they will be approved:
- The condition must be present for at least six months
- Non-surgical medical intervention must have been tried and failed to alleviate the symptoms
Medicare will deny a claim for benefits if the requested breast reduction is considered purely cosmetic.
If deemed medically necessary, Medicare will provide some benefits for the breast reduction; however, prior authorisation for the surgery will not be given. The operation will need to have already been performed for the benefits to then be provided. There are some ways to safeguard your claim by understanding the conditions that could cause a denial, and they can be found in the Local Coverage Determinations (LCD), more specifically the LCD for Mammoplasty Reduction.
It would be wise to familiarise yourself with these Medicare LCDs before assuming your procedure will be covered.
Situations considered as medically necessary
There are primary conditions that Medicare consider reasonable and necessary for a mammoplasty procedure are as follows:
- Persistent back pain and a restriction of physical activity as a result of macromastia that is not affected by conservative pain relievers, physical therapy or supportive garments
- Skin issues including infections under the breasts
- Skin irritation from the shoulder grooving of a supportive garment
These conditions must persist for more than six months with non-surgical means providing no relief. If this is the case, Medicare may provide benefits for the breast reduction procedure to rectify the issues. If approved, Medicare will allow a health fund to cover the procedure in a private hospital, which can reduce out of pocket costs by roughly half. It is important to note that this procedure is rarely available in a public hospital setting in Australia and is mostly performed in a private hospital setting where the associated fees will be higher. The Medicare item number rebate will only allow for a partial refund.
If you are at the point where you have undergone the effective breast reduction in Sydney procedure, you will then need to obtain approval for Medicare benefits by submitting a claim. The supporting documentation and information necessary can be found in the Medicare LCD which will outline the type of information required in the records you submit.
Here at the Breast and Body Clinic we are aware of the information we must provide to you; however, you may also need to include any non-surgical interventions and therapies you have tried in an attempt to alleviate your symptoms, if this is requested.
To ensure you are covered with a sufficient enough attempt to alleviate your symptoms with non-surgical methods prior to surgery you may first find out through your GP if an active metabolic or endocrine process causes your macromastia. You can try to use specific garments to alleviate symptoms, undergo physical therapy and use of dermatological remedies to relieve skin issues.
Medicare and Breast and Body Clinic
Some doctors will not accept Medicare patients for the breast reduction procedure; however, Dr. Yunaev and Breast and Body Clinic do. We pride ourselves on high-quality and caring patient experience, especially when it comes to relief from suffering to help increase your quality of life.
We also offer flexible payment options for those who are unable to receive the Medicare benefit but still wish to undergo the surgery. Simply contact us on (02) 9819 7449 or email email@example.com, and we can discuss the appropriate options to have you on the road to a more comfortable body.