Will Medicare Fund My Breast Lift? Criteria for Claiming Breast Lift Surgery on Medicare
A breast lift, also known as Mastopexy, is a surgical procedure of removing excess sagging of skin from your breast, which raises your breast and reshapes it. It helps provide proper aesthetics to your droopy breasts.
Breast lift is a primarily cosmetic surgical procedure but in certain cases, it may be medically necessary, in such cases Medicare may help fund your breast lift.
You will need to meet various strict criteria before being eligible for Medicare funding for your breast lift. Medicare will not cover you for elective plastic surgical or cosmetic procedures done purely for cosmetic purposes.
Medical reasons for having Breast Lift Surgery include
- Significant sagging of the breasts –at least two-thirds of the breast including nipples lie below the lowermost crease of your breast- Inframammary fold.
- Sagging breast leading to chronic skin infection and rashes around your breasts.
- Breast- weight-related health conditions that impact your health and consequently the quality of your life.
Eligibility Criteria for Medicare Funded Mastopexy:
Medicare has THREE criteria that are necessary to be fulfilled to be eligible for the correction of your saggy breasts by breast lift surgery include:
- A minimum of two-thirds of your breast tissue including your nipple lies below the infra-mammary fold. The nipple must lie at the lowest part of your breast contour, and
- If you have been pregnant –the breast lift surgery must be performed when your youngest child is more than 1 years of age but less than 7 years at the time of surgery, and
- There must be photographic evidence to show the changes in your breast that demonstrate the medical reasons for the breast lift.
Which Medicare Item Numbers Cover a Breast Lift – Mastopexy?
Medicare Benefits Schedule (MBS) lists item codes 45556 and 45558 in medically necessary categories for a breast lift; which are described below:
- 45558: Presence of bilateral breast ptosis. The drooping of the breasts along with the nipple must be at least two-thirds of the total breast and lie inferior to the lowermost breast crease. The nipple must be located at the lowermost and most dependent part of the inferior contour of the breast. If the patient has been pregnant –the patient is eligible if her youngest child is not less than 1 year or greater than 7 years of age. There must be photographic evidence taken from anterior, right lateral, and left lateral aspects of the breast with a marker placed at the level of inframammary fold that demonstrate a medical need for surgery.
- 45556: Presence of unilateral Breast ptosis, in cases of Breast cancer or its developmental anomalies. There must be photographic evidence in anterior, left lateral and right lateral views of the breast which demonstrate a medical need for the surgery. Diagnostic imaging evidence documented on the patient’s note that demonstrates the need for surgery may also be used. The patient will be eligible for the funding only once per occasion.
“All breast reductions include a breast lift. If you require a reduction in breast size then a breast reduction (including lift) can be done using medicare item numbers. It is also really rare to have a nipple that is photographically at the lowest point of the breast so the use of an item number for ptosis is very low. For breast reductions, this is more common, says Dr Mark.
How do I get Medicare to Cover my Breast Lift Surgery?
Medicare may provide cover for your breast lift if there is enough evidence of medical reasons and by assessing if a breast lift is the best method for treating that medical condition.
To get Medicare funding for your surgery you must:
Contact your General Practitioner or your surgeon, who will assess the degree of your breast sagging (breast ptosis) and nipple location. Your nipple must lie significantly below the inferior breast crease and two-thirds of your breast tissue must lie below the inframammary fold. After confirming the presence of changes, your medical practitioner will take photographs of the breast changes as photographic evidence is required for being eligible for Medicare funding.
Your practitioner will take a detailed history and inquire about past pregnancies- if you have been pregnant before, the age of your youngest child must be between 1 year to 7 years of age for you to be eligible for the funding for your breast lift surgery.
After checking all your conditions and your eligibility, your surgeon or general practitioner will provide you with a medical assessment citing the need for surgery.
What Other Plastic Surgery Could be Covered by Medicare Insurance?
Other plastic surgery procedures that Medicare may cover to a certain extent after fulfilling the necessary criteria’s include:
- Breast reduction surgery or Reduction Mammoplasty.
- Breast reconstruction surgery after a mastectomy.
- Breast implant placement following a mastectomy.
- Asymmetric Breasts.
- Facial or nasal reconstructive plastic surgery following cases of accident or trauma.
- Corrective nose surgery like Rhinoplasty or Septoplasty indicated breathing impairment caused by nasal injury, deviated nasal septum, or other structural abnormalities of the nose.
- Body lift surgery to tighten and remove excess sagging skin following rapid weight loss.
- Bariatric weight loss surgery for weight reduction in obesity.
- Eyelid lift surgery or blepharoplasty.
In addition to Medicare, your superannuation fund may contribute to your breast lift surgery.
Will Your Super Fund Help Pay for Your Breast Reduction and Lift Surgery?
Most Superannuation funds offer Early release of your funds for some plastic surgical procedures if you meet the criteria for compassionate release of funds. Superannuation release for breast lift surgery is based on your complaint of acute or chronic pain which requires an operation to improve these symptoms that can’t be done in the public hospital system.
Things to keep in mind before applying for the release of super fund for breast lift surgery include:
- Your condition must meet certain criteria to apply for compassionate release of funds.
- There should be necessary medical conditions necessitating the plastic surgery, as the funds will not be granted for cosmetic surgical procedures done solely for aesthetic purposes.
- It might take two to three weeks for your application to be approved
- Your Fund provider will have the final say in whether or not to approve your application for the early release of your superannuation funds.
Early release of superannuation funds may be applicable in the following plastic surgical procedures:
- Abdominoplasty or Lipectomy following weight loss
- Body Contouring or Skin Reduction Surgery after weight loss or Bariatric Surgery for obesity.
- Breast Reduction Surgery in conditions where heavy breasts lead to chronic skin conditions and posture problems in addition to chronic pain.
- Corrective Rhinoplasty for breathing problems in cases related to nasal trauma.
The ATO now handles initial applications for early release of superannuation. Companies like Supercare can assist your application for a fee.
Frequently Asked Questions (FAQs)
What is Breast Ptosis?
Breast ptosis or sagging is a condition in which your breast tissues descend downwards and outwards (Inferolaterally). Breast tissues consist of both glandular and nipple-areola complex.
Does health insurance cover a breast lift?
Breast lift is a primarily cosmetic surgical procedure but in certain cases, it may be medically needed, in such cases Medicare and Health insurance may cover part of your breast lift procedure. You will need to fulfil various criteria before being eligible for this Medicare funding of your breast lift. Your private health insurance will not cover elective breast lift surgery done for purely cosmetic purposes. In addition to Medicare funding, some Superannuation funds may provide coverage for the surgery under specific conditions.
What is a breast lift procedure? How is it done?
A breast lift, also known as Mastopexy, is a surgical procedure of removing excess sagging of skin from your breast, which raises your breast and reshapes it. It helps provide proper aesthetics to your droopy breasts. It places and lifts your breast along with your nipple at a new higher position.
Can younger patients use their superannuation funds to undergo breast lift?
In most cases, you cannot use your super funds until you reach 55-60 years of age. However, under certain conditions, you can get an early release on your superannuation funds on compassionate grounds if the surgical procedure helps in alleviating chronic pain conditions and life-threatening illnesses.
You can learn more about what procedures are funded by the Medicare Benefits Schedule at:
MBS online – MBS Online – Item numbers 45556 and 45558