Medicare Benefits Schedule - Note TN.8.96

A Medicare benefit is generally not attracted under item 45524 unless the asymmetry in breast size is greater than 10%. Augmentation of a second breast sometime after an initial augmentation of one side would not attract benefits. Benefits are not payable for augmentation mammaplasty services performed using fat transfer to the breast. 

Item 45528 applies where bilateral mammaplasty is indicated because of malformation of breast tissue, disease or trauma of the breast, (but not as a result of previous cosmetic surgery) other than covered under item 45524 or 45527.

Volumetric measurement of the breasts should be performed using a technique which has been reported in a published study. 

Related Items: 45524 45527 45528

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Multiple Operation Rule

Mammaplasty, augmentation (unilateral) in the context of:

(a) breast cancer; or

(b) developmental abnormality of the breast, if there is a difference in breast volume, as demonstrated by an appropriate volumetric measurement technique, of at least:

(i) 20% in normally shaped breasts; or

(ii) 10% in tubular breasts or in breasts with abnormally high inframammary folds.

Applicable only once per occasion on which the service is provided

(Anaes.) (Assist.)

Fee: $784.05 Benefit: 75% = $588.05

(See para TN.8.96 of explanatory notes to this Category)

Multiple Operation Rule

Breast reconstruction (unilateral), following mastectomy, using a permanent prosthesis

(Anaes.) (Assist.)

Fee: $784.05 Benefit: 75% = $588.05

(See para TN.8.96 of explanatory notes to this Category)

Multiple Operation Rule

Mammaplasty, augmentation, bilateral (other than a service to which item 45527 applies), if:

(a) reconstructive surgery is indicated because of:

(i) developmental malformation of breast tissue (excluding hypomastia); or

(ii) disease of or trauma to the breast (other than trauma resulting from previous elective cosmetic surgery); or

(iii) amastia secondary to a congenital endocrine disorder; and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

(Anaes.) (Assist.)

Fee: $1,175.90 Benefit: 75% = $881.95

(See para TN.8.96 of explanatory notes to this Category)