Abdominoplasty Medicare Cover – Will Medicare cover my Tummy Tuck?

Can Your Abdominoplasty/Tummy Tuck Be Covered by Medicare?

As you explore the possibility of abdominoplasty, one of your primary concerns may be the cost. In Australia, Medicare provides a safety net for many medical procedures, but does it cover tummy tuck – abdominoplasty? The answer isn’t a simple yes or no – it depends on your specific circumstances.

Medicare in Australia is a public health insurance scheme that provides free or subsidised health care services to eligible Australian residents. It covers a wide range of medical services, but when it comes to plastic surgery, the rules can be complex.

The distinction lies between cosmetic and medically necessary procedures. Medicare generally doesn’t cover cosmetic surgery – procedures performed primarily to alter appearance without addressing a medical issue. However, if a procedure is deemed medically necessary, Medicare may provide some coverage.

So, where does abdominoplasty fall in this spectrum? It can be either cosmetic or medically necessary, depending on your individual situation. This brings us to our next crucial point.

Medical Necessity – When Abdominoplasty Becomes More Than Cosmetic

There are instances where abdominoplasty is more than just a cosmetic procedure. Certain health issues may necessitate this surgery, potentially making it eligible for Medicare coverage.

One common medical reason for abdominoplasty is the presence of a significant abdominal apron, also known as a pannus. This excess skin and tissue can cause chronic skin infections, rashes, and hygiene issues. In severe cases, it may interfere with daily activities and mobility.

Another medical indication is diastasis recti, a condition where the abdominal muscles separate, often due to pregnancy or significant weight fluctuations. This can lead to back pain, poor posture, and even hernias.

Certain postoperative complications from previous abdominal surgeries may also necessitate reconstructive abdominoplasty.

These medical issues align with Medicare criteria for coverage. The Australian Medicare Benefits Schedule (MBS) includes specific item numbers for abdominoplasty when it’s medically necessary:

MBS Item Numbers for Abdominoplasty

Here are the item numbers for abdominoplasty in detail:

Item 30166

This item covers the removal of redundant abdominal skin and lipectomy as a wedge excision for functional problems following significant weight loss. Key points:

• Requires weight loss equivalent to at least 5 body mass index points
• Patient must have maintained stable weight for at least 6 months prior to surgery
• Not associated with certain other procedures (listed in the item description)
• Fee: $854.45 (75% benefit = $640.85)
• Multiple Operation Rule applies
• Requires anesthesia and assistance

Item 30175

This item covers radical abdominoplasty with repair of rectus diastasis, excision of skin and subcutaneous tissue, and transposition of umbilicus. Key points:

• For patients with abdominal wall defects due to pregnancy
• Requires diastasis of at least 3cm measured by diagnostic imaging
• Patient must have specific symptoms (pain, discomfort, low back pain, or urinary symptoms)
• Must have failed non-surgical conservative treatment, including physiotherapy
• Not for patients pregnant in the last 12 months
• Applicable once per lifetime
• Fee: $1,105.15 (75% benefit = $828.90)
• Multiple Operation Rule applies
• Requires anesthesia and assistance

Item 30176

This item covers radical abdominoplasty with excision of skin and subcutaneous tissue, repair of musculoaponeurotic layer, and transposition of umbilicus. Key points:

• For patients who have previously had a massive intra-abdominal or pelvic tumour surgically removed
• Not associated with certain other procedures (listed in the item description)
• Fee: $1,122.85 (75% benefit = $842.15)
• Multiple Operation Rule applies
• Requires anesthesia and assistance

Item 30177

This item covers the excision of excess abdominal skin and subcutaneous tissue following significant weight loss, in conjunction with radical abdominoplasty. It includes repair of the musculoaponeurotic layer and possible umbilicus transposition.

Key points:

• For patients with redundant skin after weight loss, causing skin issues that haven’t responded to 3 months of non-surgical treatment
• The skin must interfere with daily activities
• Weight must be stable for at least 6 months
• Fee: $1,122.85 (75% benefit = $842.15)
• Multiple Operation Rule applies
• Requires anesthesia and assistance

Item 30179

This item covers circumferential lipectomy as an independent procedure to correct circumferential excess of redundant skin and fat due to significant weight loss. Key points:

• May include radical abdominoplasty
• For cases where excess skin and fat is complicated by intertrigo or another skin condition risking skin integrity
• Condition must have failed 3 months of conventional treatment
• Excess skin and fat must interfere with daily living activities
• Weight must be stable for at least 6 months following significant weight loss
• Fee: $1,382.05 (75% benefit = $1,036.55)
• Multiple Operation Rule applies
• Requires anesthesia and assistance

It’s important to note that these item numbers have specific criteria that must all be met for Medicare coverage to apply, not just one or two.

Medicare Application Process

If you believe your need for abdominoplasty may be medically necessary, the next step is to navigate the Medicare application process. Here’s a step-by-step guide to help you through:

1. Consult with your GP: Your journey begins with your general practitioner. They can assess your condition and provide a referral to Dr Mark Kohout.
2. Specialist consultation: Meet with Dr Mark Kohout. He will evaluate your case and determine if you meet the criteria for Medicare-covered abdominoplasty.
3. Gather medical evidence: Your surgeon will help you collect the necessary medical documentation. This may include:
   • Photographic evidence of your condition        
   • Medical report from your GP of any skin conditions or infections            
   • Medical Report from non successful attempts of non-surgical correction by physiotherapist or osteopath
   • Evidence of how the condition affects your daily life
4. Keep this information available: You may receive a query from Medicare and it is handy to have all relevant medical evidence and documentation on hand.
5. Plan your surgery: You can proceed with planning your abdominoplasty with your plastic surgeon.

Keep in mind that thoroughness is important when gathering medical evidence. The more comprehensive your documentation, the stronger your case for Medicare coverage if you receive a query.

Out-of-Pocket Costs

Even if your abdominoplasty is covered by Medicare, it’s important to understand that you will still face some out-of-pocket costs. These can come in the form of gap payments and additional expenses not covered by Medicare.

Gap payments are the difference between the Medicare benefit and the fee charged by your surgeon. While Medicare sets a scheduled fee for covered procedures, surgeons are free to charge above this amount. The gap is your responsibility to cover.

Additional expenses may include:

• Anaesthetist fees
• Hospital or surgical facility costs
• Post-operative garments
• Pain medication
• Follow-up appointments

Make sure to discuss all potential costs with your surgeon before proceeding with the surgery. Dr Mark Kohout and his team are committed to transparency and will provide you with a detailed breakdown of expected costs.