Immediate Post-Operative Period: First 24-48 Hours
A breast lift, also known as mastopexy, is a surgical procedure designed to reshape and lift the breasts, also addressing the contour. While many associate this procedure with cosmetic alterations, there are instances where it can be considered medically necessary and potentially eligible for coverage under Medicare in Australia.
Mastopexy: Is It Right for You?
Mastopexy involves removing excess skin, tightening underlying tissues, and repositioning the nipple and areola to achieve a more uplifted breast shape. It addresses ptosis (sagging and drooping), often resulting from:
- Pregnancy and breastfeeding: These natural processes can stretch breast tissues and skin, leading to volume loss and heaviness.
- Significant weight loss: As you lose weight, skin elasticity may not fully recover, leaving behind excess skin and a deflated breast appearance.
- Ageing: Over time, gravity, genetics, and hormonal changes contribute to the natural loss of skin elasticity, resulting in loss of structure in the breasts.
While the primary motivation for a breast lift is often aesthetic, women also seek this procedure to alleviate physical discomfort. Large, pendulous breasts can cause back pain, neck pain, and skin irritation under the breasts, which a mastopexy can help alleviate.
Can Your Breast Lift Be Covered by Medicare?
Medicare is Australia’s universal healthcare system, providing access to affordable healthcare for all Australians. It covers a wide range of medical services, including doctor’s visits, hospital stays, and some surgical procedures.
Medicare distinguishes between procedures deemed cosmetic and those considered medically necessary.
- Cosmetic procedures are primarily aimed at altering appearance and are generally not covered by Medicare.
- Medically necessary procedures address a diagnosed medical condition, aiming to improve health and well-being. These procedures may be eligible for Medicare benefits.
Medical Necessity - When Breast Lift Becomes More Than Cosmetic
While breast lifts are often perceived as cosmetic, certain issues can make them medically necessary. In these cases, Medicare coverage may be possible.
Issues That May Necessitate Medical Mastopexy
- Breast Position: Where two third of the breat tissue lies beneath the inframammory fold.
- Areola Complex: Positioned at the lowest most dependant part of the breast contour.
- Phtographic Evidence: Pre-operative phtographs (anterior, left lateral and right lateral views) with a marker at the level of the imframammory fold must be documented in the patient’s medical record to demonstrate the clinical necessity of the procedure.
- It is important to note the Medicare benefits for this item number (45558) are applicable only once per lifetime, unless associated with specific services like breast reconstruction following mastectomy.
- Post-mastectomy breast reconstruction: In cases of breast cancer surgery, a mastopexy may be necessary to achieve symmetry and a natural-looking result during breast reconstruction.
To determine Medicare eligibility, your plastic surgeon must demonstrate that the breast lift meets the outlined criteria for a medical condition and not solely for cosmetic purposes. This requires comprehensive photographic evidence as noted above.
MBS Item Numbers for Breast Lift/ Mastopexy
Medicare Benefits Schedule (MBS) item numbers are specific codes that correspond to medical procedures and services. For breast lifts considered medically necessary, the relevant MBS item numbers may include:
This item covers unilateral correction of breast ptosis in the context of breast cancer or developmental abnormality. Photographic or diagnostic evidence must be documented to support clinical need. It applies only once per occasion and is not used in conjunction with prosthesis insertion on the same side.
- Scheduled Fee: $1065.15 (75% benefit = $798.90)
- Multiple Operation Rule applies
- Requires anaesthesia and assistance
This item covers the correction of bilateral breast ptosis through mastopexy when at least two-thirds of the breast tissue, including the nipple, is below the inframammary fold. Photographic evidence documenting clinical necessity is required. The item applies only once per lifetime unless associated with specific procedures.
- Fee: $1,308.95 (75% benefit = $981.75)
- Multiple Operation Rule applies
- Requires anaesthesia and assistance
This item covers the single-stage surgical correction of developmental breast abnormalities, which may include mastopexy, breast reduction, or the use of implants to correct significant volume discrepancies between the breasts. It is designed to address cases of congenital or developmental deformities.
- For significant breast volume asymmetry or developmental abnormalities
- Can involve mastopexy, reduction, or implants
- Fee: $1,448.30 (75% benefit = $1,086.25)
It’s important to consult with Dr Mark Kohout to determine the appropriate MBS item number for your specific situation. Please note that these amounts are subject to change, and actual rebates may vary based on individual circumstances. For the most current information, it’s advisable to consult the official MBS website.
Breast Lift Before and After Images
Photo disclaimer: Each surgical procedure produces unique outcomes influenced by factors such as body composition, skin tone, laxity, age, and genetics. The before-and-after photographs displayed are of actual patients who have consented to having their images displayed and are provided for informational purposes only. These outcomes are specific to the individuals shown and may not be representative of all patients. Surgical procedures carry risks, and results may vary. A consultation with your surgeon will provide more personalised information about potential outcomes and risks.
Mastopexy Consultation Process
- Consultation with Dr Kohout: Schedule a consultation to discuss your concerns, medical history, and desired outcomes. Dr Kohout will assess your eligibility for Medicare coverage. Keep in mind that you need a GP referral to see Dr Kohout.
- Gather medical evidence: Work with Dr Kohout to compile the necessary documentation, including photographic evidence and referral letters.
- Private Health Insurance: If you have Private Health Insurance, confirm that you are covered for Mastopexy under your current policy. If you need to upgrade your policy, there may be a waiting period.
Out-of-Pocket Costs
Even with Medicare coverage, you will still be responsible for some out-of-pocket expenses. These can include:
- Gap fees: The difference between the Medicare benefit and the surgeon’s fee
- Hospital costs: Fees for your hospital stay, operating room, and anaesthetist
Medicare typically doesn’t cover:
- Cosmetic procedures: If your breast lift is deemed primarily cosmetic, you will be responsible for the full cost.
- Private hospital costs: Medicare covers public hospital stays, but you may incur costs if you choose a private hospital and do not have Private Health Insurance or the appropriate level of cover.
Private Health Insurance - A Complementary Option
If you have private health insurance with appropriate cover, it may contribute towards some of the out-of-pocket expenses not covered by Medicare, such as:
- Private hospital costs: Your private health insurance may cover some or all of the costs associated with a private hospital stay.
- Some surgeon’s fees: Depending on your policy, your private health insurance may contribute towards your surgeon’s fees, reducing your gap payment.
- Some Anaesthetist’s fees: Depending on your policy, your private health insurance may contribute towards your anaesthetic fees, reducing your gap payment.
Potential Benefits and Considerations
- Choice and flexibility: Private health insurance allows you to choose your preferred surgeon and hospital.
- Shorter waiting times: You may experience shorter waiting times for elective surgeries like breast lifts with private health insurance.
- Additional coverage: Some policies offer coverage for post-operative care, such as physiotherapy or compression garments.
Other Payment Options
If your breast lift is not covered by Medicare or private health insurance, various financing options are available:
- Payment plans: These plans can help you manage the cost of your procedure.
- Personal loans: You can explore personal loan options from banks or other financial institutions.
Your Next Steps
How to Determine if You Might Qualify for Medicare Coverage
The best way to determine your eligibility for Medicare coverage for a breast lift is to schedule a consultation with a qualified and experienced plastic surgeon like Dr Mark Kohout.
During your consultation, Dr Kohout will:
- Conduct a thorough assessment of your medical history and concerns.
- Discuss your desired outcomes and determine if a breast lift is the right procedure for you.
- Explain the Mastopexy criteria and potential out-of-pocket costs.
- Answer all your questions and provide personalised advice to help you make informed decisions about your health and well-being.
Please feel free to contact Dr Kohout’s office to schedule your consultation.
FAQs about Medicare Cover for Breast Lift
What is the average recovery time for a breast lift, and will Medicare cover any of my time off work?
Recovery time varies depending on the extent of the procedure, but most patients need 1-2 weeks off work. Medicare doesn’t cover lost wages, but you may be eligible for government benefits like Sickness Allowance if your doctor deems the time off medically necessary.
If I’m having a breast lift for medical reasons, can I combine it with breast augmentation and still get Medicare coverage?
Medicare coverage for combined procedures is complex. Under recent Medicare changes, you can no longer claim the Mastopexy part (45558), even if medically indicated, if you add implants during the same surgical episode. Dr Kohout can explain the specifics during your consultation.
I’ve heard conflicting information about Medicare and breast reductions. Is there a difference in coverage compared to lifts?
While both procedures reshape the breasts, Medicare assesses them differently. Reductions often have stronger medical justifications due to the physical discomfort large breasts can cause. Coverage is more likely with reductions, but each case is assessed individually.
I’m not sure if my private health insurance covers breast lifts. What’s the best way to find out before my consultation with Dr Kohout?
Contact your insurance provider directly and inquire about their policy on mastopexy, specifically mentioning if it’s for medical reasons. Having this information beforehand will make your consultation with Dr Kohout more productive.
References for Medicare and Breast Lift
- Breast Uplift (Mastopexy)
- Will Medicare Cover My Plastic Surgery Procedure?
- Breast Lift (Mastopexy): Surgery & Recovery
- Breast Lift Procedure Steps
- Mastopexy (Breast Lift Surgery): Does It Really Help?
Further Reading about Breast Lift with Sydney Specialist Plastic Surgeon Dr Mark Kohout
- Read Dr Mark Kohout’s Procedure Page on Breast Lift
- Read Dr Mark Kohout’s Procedure Page on Breast Surgery Procedures
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Experienced Plastic Surgeon
Dr. Mark Kohout
A qualified plastic surgeon who operates with care and integrity, based in central Sydney with over 20 years of experience in the cosmetic field. His extensive training and experience assures patients they are in highly trained surgical hands. Dr. Kohout is a dedicated, friendly professional who is committed to providing the high quality care, support and results, alongside his compassionate team.
Dr Mark Kohout (MED0001133000)
Specialist Plastic Surgeon
Specialist registration in Surgery – Plastic Surgery