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Does Medicare Cover Breast Reduction in Australia?

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Medicare may contribute to the cost of breast reduction surgery in Australia when specific medical criteria are met. Breast reduction surgery, also known as reduction mammaplasty, is not automatically eligible for a Medicare rebate. Eligibility depends on the patient’s symptoms, clinical examination findings, diagnosis, documentation and the wording of the relevant Medicare Benefits Schedule item number.

Medicare generally does not apply to procedures performed only for cosmetic reasons. However, some patients seek breast reduction because breast size is associated with physical symptoms such as neck discomfort, shoulder discomfort, skin irritation beneath the breasts, bra strap pressure or limitations with certain activities. In these circumstances, Medicare may be relevant if the patient meets the requirements of a listed MBS item number.

This page provides general information only. It is intended for patients researching Medicare and breast reduction in Australia, including those considering consultation with Dr Mark Kohout in Sydney. Eligibility for a Medicare rebate can only be assessed after consultation, clinical examination and review of the current MBS criteria.

Dr Mark Kohout MBBS, FRACS Plast is a Specialist Plastic Surgeon consulting at Australia Plastic Surgery, Suite 2, 37 Bay St, Glebe, Sydney NSW 2037.

Breast Reduction and Medicare in Australia

The Medicare Benefits Schedule, often called the MBS, is the Australian Government list of medical services for which a Medicare benefit may be payable. MBS item numbers are procedure-specific and include wording that must be considered carefully before an item can be used.

For breast reduction surgery, the most commonly discussed Medicare item number is MBS item 45523. The current MBS wording for item 45523 refers to bilateral reduction mammaplasty with surgical repositioning of the nipple for patients with macromastia who are experiencing pain in the neck or shoulder region, and where the procedure is not performed with insertion of a prosthesis.

This does not mean every patient seeking breast reduction will meet the criteria. Medicare does not apply simply because a person is having breast surgery, has large breasts or would prefer a smaller breast size. The item number must match both the patient’s clinical circumstances and the proposed surgical procedure.

Medicare eligibility should not be assumed. An item number may apply only where the current MBS wording, the patient’s clinical circumstances and the proposed procedure align.

What Is an MBS Item Number?

An MBS item number is a Medicare Benefits Schedule listing that describes a medical service and the conditions attached to claiming a Medicare benefit. Each item number has specific requirements. These may include the diagnosis, symptoms, clinical findings, type of procedure and exclusions.

For breast reduction, an MBS item number does not apply simply because the procedure has a functional or medical component. The patient’s symptoms, examination findings and planned procedure must be considered against the current MBS wording.

For example, MBS item 45523 refers to:

  • Bilateral reduction mammaplasty
  • Surgical repositioning of the nipple
  • Patients with macromastia
  • Pain in the neck or shoulder region
  • No insertion of any prosthesis
  • Exclusions relating to certain other breast surgery item numbers

An MBS item number may also be relevant to private health insurance. Some private health funds require an eligible MBS item number before hospital cover or medical benefits are considered. However, Medicare and private health insurance are separate. A Medicare item number does not automatically mean private health insurance will cover all hospital or medical costs.

Cosmetic Breast Reduction Versus Medically Indicated Breast Reduction

Breast reduction surgery may be requested for different reasons. Some patients are mainly concerned about breast size, breast proportion or appearance. Other patients seek assessment because breast size is associated with symptoms or functional limitations.

Medicare generally does not apply to breast reduction performed only for cosmetic reasons. A breast reduction may be considered medically indicated in some cases where the patient’s symptoms, diagnosis and clinical findings meet the requirements of a relevant MBS item number.

Symptoms and concerns that may be discussed during assessment include:

  • Neck discomfort associated with breast size
  • Shoulder discomfort associated with breast size
  • Bra strap pressure or grooving
  • Skin irritation beneath the breasts
  • Difficulty with certain types of physical activity
  • Postural strain or functional limitation
  • Difficulty finding supportive garments
  • Previous treatment or management attempts
  • Duration and frequency of symptoms

The presence of symptoms does not automatically mean Medicare applies. A consultation is required to assess whether the clinical situation may meet current Medicare criteria.

Breast Reduction Medicare Item Number 45523

MBS item 45523 is an important item number for patients researching whether Medicare covers breast reduction in Australia. The item relates to bilateral reduction mammaplasty with surgical repositioning of the nipple for patients with macromastia who are experiencing pain in the neck or shoulder region, provided the procedure does not include insertion of any prosthesis.

In practical terms, assessment may include discussion of:

  • Breast size and associated symptoms
  • Neck or shoulder discomfort
  • How long symptoms have been present
  • How symptoms affect daily activities
  • Previous non-surgical management, where relevant
  • Medical history
  • Medication use
  • Smoking or nicotine use
  • Breast imaging history, where relevant
  • Physical examination findings
  • Whether nipple repositioning is part of the surgical plan
  • Whether the proposed procedure matches the MBS item wording

The item number is not applied based on the procedure name alone. Patients may refer to the procedure as breast reduction, reduction mammaplasty or breast reduction surgery, but Medicare assessment depends on the specific MBS criteria.

Are There Other Medicare Item Numbers for Breast Surgery?

In some circumstances, other MBS item numbers may be relevant to breast surgery. For example, MBS item 45520 refers to unilateral reduction mammaplasty with surgical repositioning of the nipple in the context of breast cancer or developmental abnormality of the breast.

This item is different from bilateral breast reduction item 45523. It is not used simply because a patient wants one breast reduced for cosmetic balance. The clinical context, diagnosis and surgical indication must be considered.

Examples of circumstances where other breast-related item numbers may be discussed include:

  • Breast cancer-related surgery
  • Developmental breast abnormality
  • Breast asymmetry in selected clinical contexts
  • Breast reconstruction following cancer treatment
  • Revision surgery in specific medical circumstances

The appropriate item number, if any, depends on the patient’s history, symptoms, examination findings and surgical plan.

Does Medicare Pay the Full Cost of Breast Reduction?

Medicare does not usually pay the full cost of breast reduction surgery in private practice. Where an MBS item number applies, Medicare may contribute part of the medical fee. Patients may still have breast reduction out-of-pocket costs.

These may include:

  • Surgeon’s fees
  • Anaesthetist’s fees
  • Surgical assistant fees
  • Hospital fees
  • Theatre fees
  • Garments
  • Medications
  • Pathology or imaging, where required
  • Follow-up-related costs
  • Costs associated with further treatment, if required

The current MBS listing for item 45523 includes a scheduled fee and Medicare benefit amount, but these figures do not necessarily represent the full cost of private surgery. Private fees vary depending on the surgeon, anaesthetist, hospital, procedure complexity and individual clinical factors.

Patients should receive a written estimate before surgery. This should be reviewed carefully and discussed with the clinic, Medicare and the patient’s private health insurer where relevant.

Breast Reduction, Private Health Insurance and Hospital Cover

Private health insurance may contribute to some costs if an eligible MBS item number applies and the patient’s policy includes the relevant hospital cover. However, private health insurance rules vary between policies.

The Australian Government’s private health insurance information lists MBS item 45523 under the clinical category of breast surgery that may be medically necessary. This does not mean every policy will cover every patient or every cost.

Patients should contact their private health insurer and ask:

  • Is MBS item 45523 included under my policy?
  • Is the relevant hospital category included?
  • Are there waiting periods?
  • Are there exclusions or restrictions?
  • Will hospital accommodation be covered?
  • Will theatre fees be covered?
  • Will anaesthetic fees be partly covered?
  • Will there be a gap payment?
  • What written information can the fund provide before surgery?

Patients without appropriate private hospital cover may need to consider hospital fees carefully, as these can form a significant part of the total cost.

Before and After Photos of Breast Reduction Surgery

See the difference it has made for our clients.

View Breast Reduction Gallery

Disclaimer

Individual results vary due to personal health factors and genetics, and all surgical procedures carry inherent risks that should be discussed with a qualified health professional.

Breast Reduction Patient 14 front
Breast Reduction Patient 14 45
Breast Reduction Patient 13 front
Breast Reduction Patient 13
Breast Reduction Patient 12 side
Breast Reduction Patient 12 front
Breast Reduction Patient 12 45
Breast Reduction Patient 11 side
Breast Reduction Patient 11 front
Breast Reduction Patient 10 side

Do You Need a GP Referral?

A GP referral is required to see a plastic surgeon in Australia and is often particularly relevant if a patient wishes to claim a Medicare rebate for an eligible specialist consultation. A referral also provides useful medical context, including symptoms, medical history, previous treatment and the reason for referral.

A GP referral does not determine whether breast reduction surgery meets Medicare criteria. It may support the consultation process, but eligibility for an MBS item number still requires clinical assessment.

Patients should bring their referral to the consultation. They should also check whether the referral is current, as referral validity periods may affect Medicare claiming arrangements.

What Documentation May Be Needed?

Documentation may help assess whether Medicare criteria may be relevant. The type of documentation required depends on the patient’s symptoms, medical history and the MBS item being considered.

Patients may be asked to provide:

  • GP referral
  • Medical history
  • Details of symptoms and their duration
  • Information about neck or shoulder discomfort
  • Details of skin irritation, where relevant
  • Previous treatment history
  • Physiotherapy or other allied health reports, where relevant
  • Medication list
  • Breast imaging reports, if available
  • Reports from other treating practitioners
  • Private health insurance details
  • Clinical photographs, where appropriate and with consent

Documentation does not guarantee a Medicare rebate. It assists in assessing whether the patient’s circumstances may meet the relevant MBS criteria.

What Happens During Consultation with Dr Mark Kohout?

During consultation, Dr Mark Kohout assesses each patient individually. The consultation may include review of the referral, symptoms, medical history, examination findings and relevant documentation.

Patients can discuss:

  • Why they are considering breast reduction
  • Symptoms associated with breast size
  • Functional concerns
  • Medical history and previous surgery
  • Current medications
  • Breast imaging history
  • Smoking or nicotine use
  • Surgical options
  • Risks and limitations
  • Recovery considerations
  • Possible Medicare relevance
  • Private health insurance considerations
  • Expected out-of-pocket costs

Where Medicare may be relevant, Dr Kohout can discuss whether an MBS item number may apply and what additional documentation may be required.

Dr Mark Kohout

Medicare Eligibility Does Not Guarantee Surgical Suitability

Medicare eligibility is only one part of surgical decision-making. Meeting the wording of an MBS item number does not automatically mean breast reduction surgery is suitable for a particular patient.

Surgical suitability may depend on:

  • General health
  • Medical conditions
  • Smoking or nicotine use
  • Medication use
  • Body weight stability
  • Breast tissue characteristics
  • Skin quality
  • Previous breast surgery
  • Breast imaging history
  • Wound healing risk
  • Anaesthetic risk
  • Ability to follow recovery instructions
  • Expectations and understanding of surgical limitations

Breast reduction surgery has risks, and no surgical outcome can be guaranteed. Consultation allows these factors to be discussed in relation to the patient’s individual circumstances.

Risks and Recovery Considerations

Breast reduction surgery is a significant operation. As with all surgery, there are risks and limitations that should be understood before making a decision.

Possible risks include:

  • Bleeding
  • Infection
  • Delayed wound healing
  • Visible scarring
  • Changes in nipple or breast sensation
  • Asymmetry
  • Fat necrosis
  • Nipple complications
  • Breastfeeding changes
  • Anaesthetic risks
  • Need for further surgery

Breast reduction recovery varies between patients. Time away from work, activity restrictions and follow-up requirements depend on the surgical plan, the patient’s health and the type of work or activities they perform. Patients should follow the instructions provided by their treating team and attend scheduled review appointments.

Medicare Safety Nets and Breast Reduction

Some patients ask whether Medicare Safety Nets may apply to breast reduction-related costs. Medicare Safety Nets may provide higher Medicare benefits for certain out-of-hospital services once a patient reaches the relevant threshold. Services Australia explains that Medicare Safety Nets have thresholds, and once those thresholds are reached, patients may receive higher Medicare benefits for certain Medicare services.

The Medicare Safety Net does not mean breast reduction surgery will be fully funded. It also does not automatically apply to hospital costs. Patients should check directly with Services Australia to understand how Safety Net rules may apply to their circumstances.

Why Online Medicare Information Can Be Misleading

Online information about Medicare and breast reduction can be confusing. Some websites list item numbers without explaining the criteria. Others discuss rebates without making clear that individual assessment is required.

Online Medicare information may be misleading because:

  • MBS item wording can change
  • Scheduled fees and benefits can change
  • Procedure names do not determine eligibility
  • Private health fund rules vary
  • Cosmetic and medically indicated procedures can have similar names
  • Different patients may have different symptoms and findings
  • A Medicare item number does not mean surgery is fully funded
  • Online information cannot replace consultation and clinical examination

Patients should treat online information as general guidance only. Current information should be checked through MBS Online, Medicare, the patient’s private health insurer and the treating surgeon.

Questions to Ask During Consultation

Patients considering breast reduction may wish to ask:

  • Could Medicare be relevant to my breast reduction?
  • Is there an MBS item number that may apply?
  • Does item 45523 apply to my circumstances?
  • What clinical criteria need to be met?
  • Do I need a GP referral?
  • What documentation should I bring?
  • Will private health insurance be relevant?
  • What costs may not be covered by Medicare or insurance?
  • What are the risks of breast reduction surgery?
  • What alternatives should I consider?
  • What recovery requirements may apply?
  • Could further treatment be required?
  • Are there factors that may affect my suitability for surgery?
Dr Mark Kohout

FAQs About Medicare and Breast Reduction

Can I claim Medicare for breast reduction in Australia?

Medicare may apply to breast reduction in Australia when specific MBS criteria are met. For bilateral breast reduction, MBS item 45523 may be relevant for patients with macromastia who are experiencing pain in the neck or shoulder region, provided the procedure meets the item wording. Individual assessment is required.

Does Medicare cover breast reduction for cosmetic reasons?

Medicare generally does not apply to breast reduction performed only for cosmetic reasons. Medicare may be relevant where symptoms, diagnosis, examination findings and the proposed procedure meet the criteria of a relevant MBS item number.

What is the Medicare item number for breast reduction?

The commonly discussed item number for bilateral breast reduction is MBS item 45523. It relates to bilateral reduction mammaplasty with surgical repositioning of the nipple for patients with macromastia who are experiencing pain in the neck or shoulder region. Other item numbers may apply in specific clinical contexts.

Does an MBS item number mean breast reduction is fully covered?

No. An MBS item number may allow a Medicare contribution, but patients may still have out-of-pocket costs. These may include surgeon, anaesthetist, hospital, assistant, garment, medication or test-related costs.

Can private health insurance contribute to breast reduction costs?

Private health insurance may contribute to some costs if an eligible MBS item number applies and the patient’s policy includes the relevant hospital cover. The Australian Government’s private health insurance information lists item 45523 under breast surgery that may be medically necessary, but patients must check their own policy directly.

Do I need a GP referral?

A GP referral may allow a patient to claim a Medicare rebate for an eligible specialist consultation. A referral also assists with assessment, but it does not guarantee that breast reduction surgery meets Medicare criteria.

Can Dr Kohout tell me if I qualify for Medicare?

Dr Kohout can assess whether an MBS item number may be relevant after consultation, examination and review of required documentation. Eligibility cannot be confirmed from online information alone.

Can I know my Medicare rebate before consultation?

General MBS information is available online, but individual eligibility usually requires consultation and assessment. Patients should also confirm rebate and claiming information with Medicare and their private health insurer.

Medical References

Booking a Breast Reduction Consultation in Sydney

Patients considering breast reduction surgery can schedule a consultation with Dr Mark Kohout at Australia Plastic Surgery in Glebe, Sydney. A consultation provides an opportunity to discuss symptoms, medical history, surgical suitability, possible Medicare relevance, risks, alternatives and expected out-of-pocket costs.

During consultation, Dr Kohout can assess:

  • Whether breast reduction surgery may be appropriate for your clinical concerns
  • Whether an MBS item number may be relevant
  • What documentation may be required
  • Whether a GP referral is needed for Medicare claiming purposes
  • Whether private health insurance may contribute to hospital or medical costs
  • The possible risks and limitations of breast reduction surgery
  • Recovery considerations and follow-up care
  • Estimated fees, rebates and possible out-of-pocket costs

Medicare eligibility cannot be confirmed from online information alone. Assessment requires consultation, clinical examination and review of the current MBS criteria.

Booking a Breast Reduction Consultation in Sydney

To discuss whether Medicare may be relevant to breast reduction surgery, patients can book a consultation with Dr Mark Kohout in Sydney.

Dr Mark Kohout MBBS, FRACS Plast
 Specialist Plastic Surgeon
 Australia Plastic Surgery
 Suite 2, 37 Bay St, Glebe, Sydney NSW 2037
 Phone: 1300 55 11 51

Call 1300 55 11 51 or visit Dr Kohout’s website to request an appointment.

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Dr Mark Kohout is a qualified plastic surgeon based in central Sydney, with over 20 years of experience in the field of cosmetic and reconstructive surgery. He draws on extensive surgical training and clinical experience to tailor care to the individual needs and goals of each patient.

Dr Kohout is known for his thoughtful, patient-centred approach, guiding individuals through each stage of their surgical journey — from initial consultation to post-operative care. Working alongside a compassionate and professional team, he is committed to providing high standards of care in a supportive and respectful environment.

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Disclaimer: Dr Mark Kohout (MED0001133000) a Registered Medical Practitioner, Specialist Plastic Surgeon. All surgical or invasive procedures carry risks and complications. We recommend seeking a second opinion from an appropriately qualified medical practitioner before proceeding with any surgery. Results depend on individual patient circumstances and can vary significantly. Results may also be impacted by a variety of factors including your lifestyle, weight, nutritional intake and overall health. Consult your Specialist Plastic Surgeon for details. This information is general in nature and is not intended to be medical advice nor does it constitute a doctor-patient relationship. Surgery risks and complications will be covered in detail during a consultation with your Surgeon. We recommend seeking a second opinion from an appropriately qualified medical practitioner before proceeding with surgery.

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