How To Get Insurance To Pay For Breast Reduction

Posted: Thursday March 4, 2021

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breast reduction patient

Breast reduction surgery is a tremendously rewarding procedure for patients. Many women with very large breasts feel burdened by the extra weight, frustrated that they struggle to find 'normal' clothing that flatters their shape, and sick of always needing to wear dowdy supportive undergarments instead of cute lingerie.

On top of these aesthetic concerns, large-breasted women often experience physical and emotional discomfort. Larger breasts can cause posture problems, skin rashes and upper body pain, and limit the ability to participate comfortably in physical activities. Emotionally, large breasts can take a toll in the form of unwanted attention or harassment, self-esteem issues and self-loathing.

A combination of the above factors is usually what motivates women to consider breast reduction surgery. If this procedure is on your mind, you are probably curious about whether your insurance provider may cover it. The answer to this question can be confusing for patients as breast reduction is considered an elective surgery.

Is Breast Reduction Ever Covered by Insurance?

First things first: yes, private health insurance does sometimes cover breast reduction surgery. However, some criteria must be met in order to qualify, and there will most likely still be some out-of-pocket costs. To receive cover for the procedure, Medicare must deem it medically necessary. Breast reduction surgery conducted purely for cosmetic reasons is not covered by health insurance.

When Is Breast Reduction Surgery Covered by Insurance?

Your private insurer may cover breast reduction surgery if your referring doctor says it's necessary for your health and well-being. Having large, heavy breasts that cause chronic pain and health conditions constitutes a medical reason for breast reduction surgery. You may qualify if you have any of the following symptoms:

Neck pain
Shoulder pain
Back pain
Migraine headaches
Skin irritations
Excess perspiration around or under the breasts
Shortness of breath
Numbness in the hands and fingers
Restriction of exercise and other physical activity
Underlying medical conditions, such as rheumatoid arthritis

Your doctor will need to provide information to support your claim to your insurance company.

What Level of Coverage Is Necessary for Breast Reduction Surgery?

Private health insurance is available in various tiers to suit the cover needs and budgets of different people. The specific treatments and procedures covered by these policies differ between funds, and not all tiers cover breast reduction surgery. You must have a top-level or possibly mid-level policy to receive a benefit for your breast reduction surgery.

To find out whether cover is possible for the cost of the procedure, and the level of cover available, you must check the specific terms and conditions of your health insurance policy.

What Are the Out-of-Pocket Expenses for Breast Reduction?

Even if you have medical reasons for having breast reduction surgery and have the right level of coverage with your private health insurer, you will still be liable for some out-of-pocket expenses. Generally, insurance will cover some or all of your hospital fees. You will largely be responsible for the surgeon's fee, anaesthetist's fee and assistant's fee, although there may be a small rebate available for these costs as well.

Is a Medicare Item Number Needed for Breast Reduction Surgery?

Cover from your private health insurance provider will only apply if your circumstances meet the criteria for a Medicare item number. This may require examinations, documentation, imaging tests and/or photographs from your doctor. These MBS item codes may be applicable for breast reduction:

45523 — Breast reduction surgery, bilateral (both sides) under the following condition:
- For patients with macromastia who are experiencing pain in the neck or shoulder region; and
- not with insertion of any prosthesis (breast implant)
45520 — Breast reduction surgery with surgical repositioning of the nipple, unilateral (for each single side)
- In the context of breast cancer or developmental abnormality of the breast
45522 — Breast reduction surgery without repositioning of the nipple, unilateral (for each single side)
- In the context of breast cancer or developmental abnormality of the breast

What Are the Next Steps?

You're excited about the possibilities of breast reduction surgery and you're ready to find out about your insurance options — what comes next? Schedule a consultation with a plastic surgeon to find out if you qualify. This must be an in-person appointment so your condition can be properly assessed and documented. Your plastic surgeon or a team member in your surgeon's office will inform you of the anticipated cost of your surgery and guide you through the process of applying for insurance cover.

Schedule a Breast Reduction Consultation With Dr Ellis Choy

For the many women who suffer with debilitatingly large breasts, breast reduction surgery offers profound relief, improved quality of life and a restoration of confidence. Aesthetic breast reduction is not only one of Dr Choy's most popular procedures, it is one of the most impactful and satisfying for his patients. It's an honour to give women their lives back with this transformative procedure.

Contact Specialist Plastic Surgeon Dr Ellis Choy about breast reduction in the Sydney area by calling (02) 8962 9388 or submitting an enquiry online.

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