Breast Surgery (medically necessary)

Reviewed and updated 31 March 2024

basic

bronze

silver

gold

RRestricted

OOptional

Covered

What is covered under Breast Surgery (medically necessary)?

Hospital Cover for Breast Surgery (medically necessary) covers hospital treatment to:

investigate and treat breast disorders and associated lymph nodes
perform a preventive mastectomy
perform a reconstruction and/or reduction following breast surgery.

Examples include:

breast lesions
breast tumours
asymmetry due to breast cancer surgery
gynecomastia.

This clinical category includes these treatments listed in the Medicare Benefits Schedule (MBS).

You should be aware that this category does not cover Cosmetic Surgery or Cosmetic Breast Surgery that is not medically necessary.

Some treatments you might expect to be in the Breast Surgery (medically necessary) clinical category, such as treatment for cancers, are under the Chemotherapy, Radiotherapy and Immunotherapy for cancer clinical category.

Does Hospital Cover include Breast Surgery (medically necessary)?

Tier	Clinical category covered?	Can insurers offer ‘restricted cover’?
Basic	Optional	Yes
Bronze	Yes	No
Silver	Yes	No
Gold	Yes	No

What does ‘optional’ mean?

‘Optional’ means that the Australian Government allows insurers to choose whether or not to cover the clinical category under that Hospital Cover tier.

What does ‘restricted cover’ mean?

Restricted cover means the insurer pays only limited benefits.

If insurers offer cover for Breast Surgery (medically necessary) under Basic Cover, they can do so on a ‘restricted’ basis. If you are admitted as a private patient in a private hospital for treatments under this clinical category, you will face considerable out-of-pocket costs.

You should check with your insurer before agreeing to be treated as a private patient in a private hospital if you have restricted cover for Breast Surgery (medically necessary).

Does Medicare cover Breast Surgery (medically necessary)?

Yes. Medicare covers all treatments in the Breast Surgery (medically necessary) clinical category.

If there is an MBS item number for the treatment, Medicare covers it.

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