Understanding Medicare rebates for breast implant replacement
If you’re considering having a breast implant removed and replaced, also known as breast revision surgery, you may be wondering whether Medicare will contribute to the cost. This information explains how the relevant Medicare items work so you can plan with a clear picture. It is general information only and is not a substitute for advice about your individual circumstances.
When a Medicare rebate may apply
Medicare items 45553 and 45554 cover the removal and replacement of a breast prosthesis where there is a genuine medical complication – specifically a rupture, migration of the implant material, or symptomatic capsular contracture (hardening and discomfort around the implant). Eligibility also depends on your individual clinical situation, and a rebate is not automatic even where a complication is present.
When a rebate generally does not apply
Medicare rules are more specific than many people expect. A rebate is generally not payable where:
- The original implants were inserted for cosmetic reasons (rather than in the context of breast cancer or a developmental abnormality condition), unless your surgeon can demonstrate that removing the implant would leave an unacceptable deformity in the chest contour; or
- The procedure is being done mainly to change or increase breast size.
A note about asymmetry
Many people have a slight natural difference in the size or shape of their breasts, and this is very common and normal. On its own, this kind of asymmetry – whether it was present before your original surgery or is present with your current implants – is not something Medicare treats as qualifying for these items. A difference between the breasts after one implant is removed is also not, by itself, considered an “unacceptable deformity” under the Medicare rules.
Asymmetry may support eligibility in one situation: where it was caused by a specific condition affecting how the breast developed, present before your original implant insertion. Examples include Poland syndrome, tuberous (also called tubular) breast, and significant underdevelopment of the breast. To confirm this, we will most likely need documentation from your original surgery showing that the developmental condition existed before the implants were inserted. Your surgeon will assess whether this applies to you.
What this means for you
Because eligibility depends on your specific medical history and findings, whether a Medicare rebate applies can only be confirmed by your surgeon in the context of your care. Where a rebate does not apply, the replacement is generally treated as a patient-funded procedure, and your private health insurer may also apply its own rules.
We’re happy to talk through the likely out-of-pocket costs before you make any decisions, and we encourage you to ask us any questions. Your surgeon will discuss what is clinically appropriate for you and confirm which Medicare items, if any, are relevant to your situation.
Please contact us online or call us on (08) 9380 0333 and one of our medical secretaries can provide you with more information.
