Breast reduction attracts a Medicare rebate under item 45523 when you have macromastia causing pain in the neck or shoulder region, and no implant is used at the same time. The Medicare benefit is 75% of the schedule fee for that item.
That rebate applies to the surgeon’s fee only. It is one part of what you pay, not the whole of it.
Item 45523 at a glance
| Item number | 45523 |
| What it covers | Reduction mammaplasty, both breasts, with surgical repositioning of the nipple |
| Clinical requirement | Macromastia with pain in the neck or shoulder region |
| Excluded | Any procedure inserting a prosthesis (implant) at the same time |
| Medicare benefit | |
| Referral | A GP referral is required to see Dr Kumar |
Figures are the MBS schedule fee and benefit as at 1 July 2026. The schedule fee is what Medicare sets, not what a surgeon charges.
What “medically necessary” actually means here
The item does not turn on breast size alone, and there is no cup size that qualifies you. Two things have to be true: the breasts are large enough to be classed as macromastia, and that size is causing pain in your neck or shoulders.
In practice, Dr Kumar is looking at whether your symptoms fit that description and are documented. The things that tend to matter:
- Neck, shoulder or upper back pain that you can date, and that has been raised with your GP
- Grooving of the shoulders from bra straps
- Rashes or skin breakdown under the breast fold that keep coming back
- Whether physiotherapy, supportive bras or weight loss have already been tried
- Postural change and restriction of activity
Bring your GP records to the consultation. A patient whose symptoms have been recorded over time is on much firmer ground than one describing them for the first time.
What the rebate does not cover
This is where most patients are caught out. Medicare’s benefit covers a portion of the surgeon’s fee. It does not pay for:
- The hospital, including theatre and your bed. That is where private health cover matters.
- The anaesthetist, who bills separately and attracts a separate, smaller rebate.
- The surgical assistant, where one is needed.
- Garments, dressings and follow-up outside the standard post-operative period.
Dr Kumar’s quotes are itemised so you can see each of these separately, with the Medicare and health fund contributions shown against them. The hospital provides its own quote after checking your fund. Read more about costs and payment.
If an implant is involved, the item does not apply
Item 45523 specifically excludes cases where a prosthesis is inserted. If your plan involves a reduction combined with an implant, that is a different operation and this rebate is not available for it. It is worth raising early, because it changes the cost materially.
Can you have it done in the public system?
Yes, breast reduction is performed in public hospitals for symptomatic macromastia, through a public outpatient referral. Waiting times vary by area and are often measured in years rather than months. Dr Kumar consults privately at Westmead, Penrith and Orange, and operates at Westmead Private Hospital.
Does private health insurance cover the rest?
If you hold hospital cover that includes this category and have served your waiting periods, your fund generally contributes to the hospital and theatre costs. It does not remove the gap on the surgeon’s or anaesthetist’s fees. Your fund can confirm your cover against the item number above before you commit to anything.
How the assessment works here
- GP referral. Required to see Dr Kumar. Ask your GP to note the history of your symptoms.
- Phone consultation with one of Dr Kumar’s nurses, who will tell you what to bring.
- Consultation with Dr Kumar, about 90 minutes, including examination, photographs and measurements. The consultation fee is $400, with a Medicare rebate of approximately $88.
- An itemised quote covering the surgeon, anaesthetist, assistant, hospital and garments, after your fund has been checked.
- A cooling-off period of at least seven days, then a second appointment with Dr Kumar for your questions and consent.
Common questions
What is the 45-55 rule?
This refers to older private health fund criteria, not to Medicare. Item 45523 does not use it. What the item requires is macromastia with neck or shoulder pain.
How many sizes will I go down?
Dr Kumar plans the reduction around your frame and your symptoms rather than a target cup size, because bra sizing is not standardised between brands.
Do I need to lose weight first?
If you are actively losing weight, your result will change as you do. Dr Kumar will discuss timing with you rather than applying a fixed rule. If you are still losing, read about body contouring after major weight loss.
Will Medicare cover a lift without a reduction?
No. A mastopexy performed for shape alone does not attract a rebate under this item.
Next step
If neck or shoulder pain is the reason you are reading this, ask your GP for a referral and bring it to a consultation. Dr Kumar’s nurses can talk you through what to expect first. Call 1300 267 726 or request a call through the enquiry form. More about breast reduction surgery.
All surgery carries risks, and individual results will vary. Read more about the risks of surgery here. A GP referral is required to see Dr Kumar.
Dr Rohit Kumar (MED0001630444) Registered medical practitioner, specialist plastic surgeon (specialist registration in surgery – plastic surgery).
