Does Medicare cover gynaecomastia surgery? Does private insurance cover male breast reduction? These are questions patients often ask Dr. Bernard Beldholm, a gynaecomastia surgeon in Australia. This article talks about how to qualify for Medicare rebates, rules, insurance coverage and how much gynaecomastia surgery costs.
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What is Medicare?
Medicare is Australia’s universal health system.
What does Medicare cover?
It covers surgery procedures that are deemed medically necessary. Procedures that are done for aesthetic reasons do not qualify. When a procedure is classified as medically necessary, a Medicare item number is assigned to it. This is listed in the Medicare Benefits Schedule (MBS). If your surgery has an item number and you meet certain criteria, you can receive a partial rebate for surgery. There are plenty of exclusions, so keep reading.
How do I claim a Medicare rebate?
Some cosmetic reconstructive procedures qualify for a rebate. To claim a rebate, a GP must refer you to a specialist surgeon. The surgeon determines whether your procedure is medically necessary or cosmetic. If it is medically necessary, then this is what happens next. You’ll have the surgery. After the surgery, you will receive a receipt. You can then submit the bill as a claim to your health fund in order to receive a partial rebate.
Does Medicare cover gynaecomastia surgery?
The gynaecomastia operation is not done in the public health system. It is done in the private system. Medicare does not pay for private hospitals, as this is considered an out-of-pocket expense. Private health insurance may cover this cost if a Medicare item number applies to your surgery AND you have the right level of cover. The amount you get back varies from health fund to health fund.
What is the item number for gynaecomastia?
There is an MBS item number for gynaecomastia surgery if it is deemed medically necessary or reconstructive. The item number for gynaecomastia surgery is 31525: “Breast subcutaneous mastectomy for gynaecomastia”.
What are the rules for using MBS Item 31525 for gynaecomastia?
The surgery must be medically necessary or reconstructive in nature. You must have a history of chronic pain and/or a breast gland of significant size. Your specialist surgeon must verify all this. You have to have top cover. You must have gynaecomastia for 12+ months. The surgery must take place in an accredited hospital. If a surgeon offers liposuction-based gynaecomastia surgery in a private facility (i.e. not a hospital), you cannot claim the item number. Other exclusions may apply.
Does insurance cover gynaecomastia surgery?
If you have a private health plan, it may reimburse you for some or all of the hospital fees, depending on your level of coverage. The surgeon fee is an out-of-pocket expense.
When will you receive the rebate?
A rebate means you have to pay the fees out-of-pocket first. You’ll be provided with a receipt upon paying the surgery bill. If you qualify for the gynaecomastia item number, you can submit a claim to your health fund. Assuming you meet all the qualifications above, you’ll receive a portion of the surgery cost back as a rebate. The full cost of surgery is not reimbursed. Usually, it is just the hospital stay and anaesthetist fees that you’ll get back. Again, this varies based on the health fund.
How much does gynaecomastia surgery cost in Australia?
The average cost of gynaecomastia surgery ranges from $3,000 to $6,000 AUD. This may include the surgeon fee, hospital fees, anaesthesiologist and other items.
Hospital fees
If you have top-level hospital coverage, hospital fees may be covered fully. Without health insurance, you’ll pay for hospital fees out of pocket. This costs approximately $2,000 to $4,000 on average.
Each day in the hospital adds to the cost. Most patients stay overnight. Gynaecomastia surgery takes around two hours, plus time in the recovery room as you wake from anaesthesia. If you have a longer hospital stay due to complications, which are thankfully rare, that may be covered if you have top-level hospital coverage.
Anaesthetist fee
An anesthesiologist is a doctor that administers sedative drugs before surgery. You will be fully sedated with general anesthesia during your gynaecomastia surgery. There will be no memory or sensation of the procedure. You will wake up in a recovery room with a flatter chest.
Anaesthesiologists also monitor your vitals during surgery. They check your breathing and heart rate while you are in the O.R. This allows your surgeon to focus on your operation. Anaesthetists go through many years of medical training. Their job is very important. They ensure you are safe from the moment you go under sedation to when you wake up.
Like surgeons, anaesthetist fees vary. Some charge more than others. Pricing varies based on years of experience, training and geographic location.
Surgeon fee
The surgeon fee usually varies based on years of experience. That means a more skilled surgeon is likely to cost the most. In general, higher prices reflect more service and, theoretically, better results for patients.
The surgeon cost also depends on the type of surgery you need. There are two kinds of gynaecomastia surgery:
Gynaecomastia surgery with breast gland removal
In men with true gynaecomastia, the breast gland is faulty. An overactive gland makes breasts grow more than they should. The gynaecomastia treatment in this case is surgical removal of the gland. Breast liposuction may be done to reduce male breasts as well.
Male breast reduction without gland removal
Some men don’t have true gynaecomastia. Instead, they have what is known as pseudo-gynaecomastia. That means they have male breast enlargement that looks similar to gynaecomastia, but there is nothing wrong with the breast gland itself. Genetics, body fat distribution and being overweight are common causes.
Male breast reduction is done to reduce fat and reshape a normal, flat chest in men with pseudo-gynaecomastia. The gland is not removed, since there is nothing wrong with it. Since the gland stays intact, the procedure is less invasive. Thus, it may cost less than a full gynaecomastia surgery with gland removal. Since the surgery is done for cosmetic reasons, the health fund rebate is not applicable.
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How much does Dr. Beldholm charge for gynaecomastia surgery?
A lot of Australia gynaecomastia won’t reveal prices online or by phone. Dr. Bernard Beldholm believes in transparent pricing. This allows his patients to plan for the cost of surgery. His current gynaecomastia pricing can be found on this page.
What does Dr. Beldholm’s surgeon fee include?
- Surgical fee for Dr. Beldholm
- Two (2) compression garments
- Six (6) post-op appointments
- Six (6) LED light treatments
What is not included?
Dr. Beldholm’s fee just represents the surgeon fee and related items listed above. The hospital fee and anaesthetist fee are separate charges. Those fees are billed separately.
Learn more about Australian Medicare rebates for cosmetic surgery
Dr. Beldholm is a body contouring surgeon in Australia that helps men and women improve their bodies so they can look great in clothes. While not all patients are eligible for health fund rebates for cosmetic surgery, it’s possible if the surgery is deemed medically necessary. Book a private consultation for more information.