Medicare Cover for Mastopexy Surgery

A breast lift, medically referred to as mastopexy, involves the removal of excess skin and tightening of the surrounding tissue to reshape and support the new breast contour. Often, women seek this surgery to restore the breast shape lost after pregnancy, breastfeeding, weight fluctuations, or ageing. Despite being a popular procedure, the road to securing Medicare coverage for a breast lift is not straightforward. The complexity arises from Medicare’s stringent criteria which must be met for the procedure to be classified as medically necessary rather than purely cosmetic. Eligibility for coverage under Medicare requires that the procedure addresses specific functional health issues, such as back pain or skin conditions, which can complicate the approval process. Understanding these criteria and proving medical necessity is essential for anyone considering this procedure and hoping to receive financial support from Medicare.

In this blog, Sydney Specialist Plastic Surgeon Dr Bish Soliman aims to provide you with a clear, detailed understanding of these criteria, how the process works, and what steps you need to take if you are considering this surgery.

What is Breast Lift Surgery?

A breast lift, or mastopexy, is a surgical procedure aimed at raising and reshaping sagging breasts. Over time, factors such as pregnancy, nursing, and gravity can affect the shape and firmness of the breasts. During the surgery, excess skin is removed, breast tissue is reshaped, and the nipples may be repositioned or resized to achieve a natural appearance. The goal is to restore the breasts to a more upright and firmer position. When considering a breast lift, it is important to understand the distinction between cosmetic enhancements and medically necessary procedures, as this impacts Medicare coverage.

Medicare is Australia’s public health insurance system, providing residents with access to a wide range of health services at low or no cost. It covers various treatments, including some surgical procedures, doctor visits, and more. However, the coverage for surgical procedures, especially those deemed cosmetic, is limited. For a procedure to be covered, it must be considered medically necessary. Understanding what constitutes medical necessity and how it applies to breast lift surgery can help you assess whether you might be eligible for coverage.

Medicare Coverage for Plastic Surgery

Medicare distinguishes between cosmetic surgery and reconstructive surgery when it comes to coverage. Cosmetic surgery is generally performed to improve appearance without a medical need, and it is typically not covered by Medicare. On the other hand, reconstructive surgery is performed to correct abnormalities caused by congenital defects, developmental abnormalities, trauma, infection, tumours, or disease. It is often covered by Medicare because it is considered medically necessary. Understanding this distinction is vital when considering breast lift surgery. If the surgery is purely for enhancing appearance, it might not be covered. However, if it is to correct abnormalities or after significant weight loss or childbirth where medical issues arise, such as back pain or skin conditions, Medicare may cover some of its costs.

Medicare Coverage for Breast Lift Surgery

When it comes to breast lift surgery, Medicare’s coverage is quite specific and only applies under certain conditions. Medicare will generally cover the costs of a breast lift if the procedure is considered medically necessary—that is, not merely for improving appearance but required to address significant physical issues caused by, for example, significant breast asymmetry, back pain, shoulder pain, or other health concerns directly linked to the condition of the breasts. It’s important to understand that the necessity must be well-documented. Your plastic surgeon will need to provide a detailed report explaining why the breast lift is essential for your health. This documentation is important when submitting a claim to Medicare for coverage. In this context, the specific item numbers 45558 and 45556 come into play, which we will explore in more depth. These item numbers outline the criteria under which Medicare provides coverage, detailing the necessary conditions and the type of surgical procedures included.

MBS Item Numbers for Breast Lift Surgery

Item numbers 45558 and 45556 are essential components within the Medicare framework. Each code specifies the conditions and surgical procedures it covers, thereby streamlining the Medicare claims process:

Item Number 45558: This code is typically used when breast lift surgery is necessary for both breasts. Eligibility for coverage under this item number requires medical justification, rather than purely aesthetic motivations.
Item Number 45556: This code is generally reserved for breast lift surgeries that are performed on just one breast. This might occur in cases related to breast cancer treatment or congenital anomalies.

The Process of Claiming Medicare for Breast Lift Surgery

The process of claiming Medicare benefits for breast lift surgery requires careful preparation and attention to detail. Once Dr Soliman has determined that your procedure meets the necessary criteria under Medicare item numbers 45556 or 45558, the next steps involve documentation and submission of your claim. Initially, Dr Bish and medical team will help you gather all necessary medical records, surgical plans, and justifications for the surgery’s necessity. This collection of documents must clearly demonstrate that the surgery is not for cosmetic purposes but is essential for treating a medical condition or correcting a functional impairment.

After compiling the documentation, Dr Soliman’s team will submit a claim to Medicare on your behalf. This claim will detail the surgery, include the specific item number applicable to your case, and provide all supporting medical evidence. It is important that this information is thorough as Medicare will review it to decide if they will cover the procedure. If there are any issues with the claim or additional information is needed, Medicare may contact Dr Soliman or you directly.

Once submitted, the processing time can vary, so it is wise to have an understanding of the expected timeline and any potential out-of-pocket costs that might be incurred during this period. If Medicare approves the claim, they will cover a portion of the surgery costs directly related to the medical necessity. However, it’s important to understand that there may be related costs that are not covered, such as fees for the surgical facility or post-operative care, which will need to be planned for financially.

Keep in mind that you need a GP referral to see Dr Soliman if you plan to get Medicare cover for your breast lift surgery.

What If Medicare Doesn’t Cover Your Surgery?

In cases where Medicare does not cover your breast lift surgery, you might need to explore other financial options. Some patients turn to private health insurance to see if it can provide partial coverage for procedures that Medicare does not cover. It’s important to check with your insurance provider about the specifics of your policy, as coverage can vary significantly based on the plan.

Alternatively, there are payment plans that allow you to pay for the procedure over time. Discussing these options with Dr Soliman’s team can provide you with a manageable way to finance your surgery without the immediate financial burden. It’s also worth exploring any subsidies or financial assistance programs available for those who meet certain criteria, such as low-income earners or those with specific health conditions.

Common Reasons for Denial of Coverage

Understanding why Medicare claims for breast lift surgery are denied can help you better prepare your application. Common reasons for denial include a lack of evidence of medical necessity, insufficient documentation, or the procedure being deemed cosmetic rather than reconstructive. To avoid these pitfalls, ensure all medical records clearly document the physical symptoms caused by your breast condition and include detailed notes from Dr Soliman. Also, double-check that all forms are filled out correctly and completely before submission.

FAQs about Medicare and Breast Lift

Can I use Medicare for a breast lift if there are no physical symptoms but significant psychological distress?

Medicare coverage is generally based on physical health needs and medical necessity. Psychological distress alone typically does not qualify for coverage under Medicare for procedures like breast lifts. However, if psychological issues are linked to physical symptoms, it may be considered. It’s best to consult with your GP or Dr Soliman to discuss your specific situation.

Does Medicare cover the full cost of breast lift surgery if it’s deemed medically necessary?

If Medicare approves the surgery, they will cover a portion of the costs associated with the procedure. However, you may still be responsible for out-of-pocket costs, including deductibles, co-payments, and any charges exceeding the amount Medicare agrees to pay. It’s advisable to discuss these potential costs with Dr Soliman’s team.

How long does it typically take for Medicare to process a claim for breast lift surgery?

The processing time for Medicare claims can vary, but generally, it takes about 30 days for Medicare to process a claim once all required documentation has been submitted. If additional information is needed or if there’s an appeal, the process may take longer.

What should I do if my circumstances change after receiving approval for breast lift surgery under Medicare?

If your medical condition changes or if there are any significant changes to your circumstances (such as additional health issues or changes in your weight), it’s important to notify Dr Soliman and Medicare. These changes might affect your eligibility or the specifics of the coverage approved by Medicare.

Are there any specific surgeons or hospitals that I must use to have my breast lift surgery covered by Medicare?

Medicare generally allows you to choose your own surgeon and hospitals, as long as they are enrolled in the Medicare program. However, using a Medicare-approved provider and a facility that accepts Medicare patients ensures that your costs are covered according to the terms of your Medicare plan. Always verify that your chosen provider and facility are approved by Medicare to avoid unexpected charges.

Medical References about Breast Lift

Breast augmentation vs breast lift – picking the right procedure – American Society of Plastic Surgeons
What you need to know about breast augmentation – Medical News Today
Breast lift vs breast augmentation vs breast implants – American Society of Plastic Surgeons
What are the risks of breast implant surgery? – Medical News Today

Medicare Cover for Mastopexy Surgery?