Does Private Health Insurance Cover Tuberous Breast Surgery?
Understanding Medicare rebates, private hospital cover and out-of-pocket costs for tuberous breast correction in Australia.
Tuberous breast is a developmental breast abnormality that can affect the shape, symmetry and development of one or both breasts. In some circumstances, surgery to correct tuberous breasts may meet the criteria for a Medicare Benefits Schedule (MBS) item number.
Where an eligible MBS item applies, Medicare may provide a rebate towards your medical fees and, if you have appropriate private hospital insurance, your health fund may also contribute towards eligible hospital costs.
However, having tuberous breasts does not automatically mean your surgery will be covered. Eligibility depends on the clinical findings, the procedure being performed and whether the relevant Medicare criteria are met. Your private health insurance policy, waiting periods and level of hospital cover will also affect what your insurer contributes.
In this guide
When tuberous breast surgery may qualify for Medicare
Which Medicare item numbers may apply
What Medicare and private health insurance actually pay
How waiting periods and pre-existing condition rules work
What to ask your health fund before booking surgery
What is tuberous breast?
Tuberous breast is a developmental abnormality that occurs as the breast develops, usually becoming apparent during puberty.
The presentation varies considerably between patients and may affect one or both breasts. Features can include differences in breast shape or volume, a constricted breast base, a high inframammary fold, enlarged or prominent areolae and breast asymmetry.
During your consultation, Dr Katie-Beth Webster will perform a physical assessment and document relevant measurements and clinical findings. Photographs and, where appropriate, other diagnostic evidence may also form part of the documentation required to support an eligible Medicare item.
Importantly, small breast size alone does not necessarily meet the Medicare criteria for a developmental breast abnormality. The applicable MBS item depends on the specific anatomical findings and proposed treatment.
Which Medicare item numbers may apply?
Several Medicare item numbers may apply to correction of developmental breast abnormalities. Each has specific clinical criteria, and the appropriate item depends on whether one or both breasts are affected and whether surgery is performed in one or two stages.
Dr Webster will determine whether an MBS item is clinically applicable and include the proposed item number or numbers in your surgical quote where appropriate.
Correction of both breasts
45060 — Single-stage correction of a developmental breast abnormality
45061 — Two-stage correction, first stage
45062 — Two-stage correction, second stage
Correction of one breast
45070 — Single-stage correction of a developmental breast abnormality
45071 — Two-stage correction, first stage
45072 — Two-stage correction, second stage
Items 45070–45072 were introduced from 1 July 2026 as unilateral equivalents of the existing bilateral items.
Other items that may apply
Depending on the surgical plan, other MBS items may sometimes be relevant, including:
45524 — Unilateral augmentation mammoplasty in specific circumstances involving breast cancer or a developmental breast abnormality
45534 / 45535 — Autologous fat grafting to the breast where the relevant clinical criteria are met
The existence of an item number does not mean it will apply to every patient or every tuberous breast procedure. The relevant criteria must be met and documented.
What does Medicare actually cover?
A Medicare rebate is a contribution towards the medical service, not payment of the total cost of surgery.
If your procedure meets the criteria for an eligible MBS item, Medicare pays the applicable benefit associated with that item. Your private health insurer may also contribute towards eligible medical and hospital costs if your policy includes the relevant hospital treatment.
Your total cost may still include:
the surgeon’s fee and any gap above the Medicare or health fund benefit
anaesthetist fees
hospital excess or co-payment
costs not covered by your policy
other expenses associated with your treatment
Private surgeons set their own fees, so having an MBS item number does not mean surgery will be free.
Will my private health insurance cover tuberous breast surgery?
Whether your private health insurer contributes depends on several factors.
1. Does your policy include the relevant hospital treatment?
Having private hospital insurance does not necessarily mean every type of surgery is covered.
Before booking surgery, contact your insurer with the MBS item number or numbers supplied by Dr Webster’s rooms and ask whether your policy provides hospital benefits for that treatment.
It is also worth asking about:
exclusions or restrictions
your hospital excess or co-payment
whether the proposed hospital has an agreement with your insurer
whether prostheses or implants have any associated costs
2. Have you completed any applicable waiting period?
Private health insurers may apply waiting periods when you first take out hospital cover or increase your level of cover.
For hospital treatment involving a pre-existing condition, the maximum waiting period is generally 12 months.
Under private health insurance rules, a condition may be considered pre-existing if signs or symptoms existed during the six months before you joined or upgraded your cover. The insurer’s appointed medical practitioner determines whether the pre-existing condition rule applies.
Because tuberous breast is a developmental condition, this may be relevant for some patients, but it should not be assumed automatically. It is important to confirm your individual position directly with your health fund.
You may still be able to proceed with consultation and surgical planning while serving a waiting period.
3. What will your out-of-pocket costs be?
Your health fund may have agreements with particular hospitals or medical providers that affect the gap you pay.
Before surgery, ask the surgeon, anaesthetist, hospital and health fund for information about the expected costs and benefits that apply to your treatment.
“Covered” does not necessarily mean there will be no out-of-pocket cost.
What should I do next?
1. Book a consultation
If you are seeking a Medicare rebate for your specialist consultation, you will generally need a valid referral from your GP or another appropriate medical practitioner.
During your consultation, Dr Webster can assess your breast anatomy, discuss your concerns and determine whether your presentation may meet the criteria for a relevant MBS item.
2. Ask for the proposed Medicare item numbers
If an MBS item applies, the proposed item number or numbers can be included with your surgical quote.
You can then provide these numbers to your private health insurer.
3. Contact your health fund
Ask your insurer:
Is this MBS item covered under my current hospital policy?
Have I completed all applicable waiting periods?
Will the pre-existing condition rule apply?
Is the proposed hospital covered?
What excess or co-payment will I need to pay?
Are there any restrictions relevant to implants or prostheses?
Ask for a reference number for the conversation so you have a record of the advice provided.
4. Request written information about your costs
Where possible, ask for written quotes and benefit information so you understand the likely surgeon, anaesthetic and hospital costs before proceeding.
If your insurer advises that the procedure is not covered, ask why. If the reason relates to a waiting period, you may simply need to wait until that period has been completed. If there is uncertainty around the applicable item number or clinical criteria, contact Dr Webster’s rooms for clarification.
Concerned about tuberous breast development?
A consultation with Dr Katie-Beth Webster can help determine whether you have features of tuberous breast, discuss the surgical options available and establish whether a Medicare item may apply to your treatment.
Frequently asked questions
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It may be.
Medicare rebates are available for certain procedures used to correct developmental breast abnormalities when the relevant MBS criteria are met.
Eligibility depends on the clinical presentation and the procedure required. Being diagnosed with tuberous breasts does not automatically mean every surgical option will qualify for a Medicare rebate.
Dr Webster can assess whether an MBS item may apply during your consultation.
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Private hospital insurance may contribute to eligible hospital and medical costs where the procedure has an applicable MBS item and your policy covers the relevant hospital treatment.
Your level of cover, waiting periods, exclusions, hospital arrangements and excess can all affect what your insurer pays.
Always confirm coverage directly with your health fund using the MBS item numbers supplied by your surgeon.
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In some circumstances, breast augmentation may form part of reconstructive treatment for a developmental breast abnormality.
However, Medicare item criteria are specific and depend on the anatomy and procedure being performed. Dr Webster will advise which surgical approach and, where appropriate, MBS item numbers apply to your individual case.
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Not necessarily.
Where surgery meets the criteria for correction of a recognised developmental breast abnormality under an applicable MBS item, it may be treated as reconstructive surgery for Medicare purposes.
If those criteria are not met, treatment may be considered cosmetic and Medicare and private hospital benefits linked to an MBS item may not apply.
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A GP referral is generally required if you want to claim a Medicare rebate for your specialist consultation.
A referral also allows your GP to provide relevant medical history and helps coordinate your care with Dr Webster.
