Tummy tuck surgery, also known as abdominoplasty, is a popular procedure for mothers seeking to followimprove the appearance or functionality of their abdomen after having children.
When it comes to insurance coverage, the eligibility and extent of Medicare’s involvement can be a topic of uncertainty. In Australia, Medicare provides coverage for procedures deemed medically necessary, and the coverage for tummy tucks is limited to specific circumstances.
Below, we delve into the intricacies of Medicare coverage for postpartum tummy tuck surgery, exploring the criteria for medical necessity, the history of coverage changes, the role of private health insurance and the considerations you should keep in mind if you are interested in this procedure.
By understanding these factors, you can make informed decisions about your options and potential financial obligations. The Pure Aesthetics team is always here to help if you have questions.
Is a Medicare Rebate Available for Tummy Tucks in Australia?
Some tummy tuck procedures may be partially covered by Medicare. This applies only to tummy tucks that are deemed medically necessary, meaning the procedure is essential for the diagnosis or treatment of a specific health condition and is not performed solely for cosmetic reasons.
There are strict criteria for determining what is medically necessary. Your plastic surgeon and GP must both agree that undergoing a tummy tuck could correct or improve a functional impairment or address a significant medical condition.
What Might Make a Tummy Tuck Medically Necessary?
Postpartum abdominoplasty can be medically necessary if the condition of your abdomen interferes with your day-to-day life.
If you are postpartum and suffer from rectus diastasis (separation of the large abdominal muscles), you may qualify for Medicare assistance. Rectus diastasis can significantly affect the functionality and stability of your core, causing discomfort and activity limitations that may affect your quality of life. These are regarded as medical matters in Australia, not just cosmetic. As a result, a tummy tuck for postpartum patients is now included in the Medicare Benefits Schedule (MBS).
A tummy tuck may also be considered medically necessary under the following circumstances:
- You have excess skin that is causing intertrigo or another skin condition
- You are experiencing chronic constipation or low back pain
- You struggle to exercise or maintain good posture
- You have urinary incontinence caused by torn abdominal muscles
Why Was Postpartum Abdominoplasty Removed From the MBS in 2016?
In December 2015, the Federal Government announced that the item number for postpartum abdominoplasty would be removed from the MBS on 1 January 2016. This action was taken due to concerns that it provided a loophole to fund cosmetic surgery. Without an item number, neither Medicare nor private health insurers could cover the procedure.
Why Was a New Item Number for Postpartum Abdominoplasty Introduced in 2022?
In response to recommendations from the Independent Medical Services Advisory Committee (MSAC), the Federal Government decided to reintroduce postpartum abdominoplasty to the MBS five years after its removal. The new item number came into effect on 1 July 2022.
Will My Costs Be Fully Covered? Can I Get a Tummy Tuck for Free?
Tummy tuck surgery is not free. Medicare (and/or a private health insurer) may offer a partial subsidy for the procedure only. There will be an out-of-pocket gap payment for your surgery that you will be responsible for.
The factors below will impact how much you will pay:
- Medicare eligibility
- Private health insurance status and coverage
- Surgeon’s fee
- Assistant Surgeon’s fee
- Anaesthesia fees
- Hospital or surgical facility costs
- Prescriptions for medication
- Post-surgery garments and supplies
- Medical tests, if need
Our team will be able to discuss these in more detail with you during your consultation.
What MBS Item Number Is Relevant For Mums Seeking a Tummy Tuck?
As of 1 July 2022, there is a new MBS item (30175) for radical abdominoplasty that includes repair of abdominal muscle separation following pregnancy.
To claim a Medicare tummy tuck, your surgery must be medically required. Only a trained professional can determine whether you qualify. This means you will need to visit a doctor who can assess your concerns, document your condition and provide you with a referral.
This item number is applicable once per lifetime.
What Do I Have to Demonstrate to Qualify for This Item?
According to the official descriptor, you must meet ALL of the following criteria to qualify for item 30175:
- Have an abdominal muscle separation measuring at least 3cm, as determined by diagnostic imaging prior to the procedure
- Have symptoms of moderate to severe pain or discomfort at the site of the diastasis in the abdominal wall during use of the muscles, and/or low back pain or urinary symptoms
- Have rectus diastasis documented in your medical records by the practitioner providing the surgery
- Have attempted to manage the condition with nonsurgical conservative treatments, including physiotherapy, without success
- Have not been pregnant in the last 12 months
Additionally, your tummy tuck must not be associated with a service to which item 30165, 30651, 30655, 30168, 30171, 30172, 30176, 30177, 30179, 45530, 45564 or 45565 applies.
Item descriptors and other information related to the Medicare Benefits Schedule can be found on the MBS Online website.
What If I Just Don’t Like the Look of My Stomach After Pregnancy?
If you are interested in removing excess fat and skin from your tummy, but do not have functional impairment due to an abdominal muscle gap, your tummy tuck would be considered cosmetic. Medicare does not cover cosmetic plastic surgery. Therefore, you would be expected to pay the full cost of the procedure with no rebate from Medicare or a private health insurer.
Medicare maintains tight eligibility criteria for abdominoplasty to avoid the misuse of Medicare funding. Medicare has stated that it plans to conduct a review of usage of this procedure two years after its implementation in July 2022. If there are concerns it is being misused for cosmetic purposes, it could be removed from the MBS.
Who Decides If I Am Eligible to Have My Tummy Tuck Covered by Medicare?
The decision ultimately rests with your Specialist Plastic Surgeon. However, they are not the only professional you will need to see.
Before consulting with a Specialist Plastic Surgeon in Sydney, you will first need to see your GP for nonsurgical management and treatment options. When speaking with your GP, make sure you bring up any functional limitations or health concerns you’re experiencing. This will ensure your symptoms are documented. Your GP will then make the referral for the abdominoplasty if medical necessity is established.
You may see other professionals as part of this process. For instance, you may need to work with a physiotherapist to show that your concerns cannot be alleviated with nonsurgical measures. You may also need to visit a radiologist who can measure the size of the gap between your abdominal muscles with ultrasound imaging to ensure it meets the minimum requirement of 3cm.
Do I Need to Have a Referral From My GP?
Yes. Your tummy tuck must be seen as a medical necessity by your GP. You will need a valid referral at the time of your surgery. A GP referral lasts for 12 months.
How Do Private Health Funds Factor Into the Cost of Tummy Tuck Surgery in Australia?
Here in Australia, Medicare covers most Australian residents for health care. However, the public health system does not cover everything, and some people choose to take out private health insurance for more comprehensive cover and a wider range of healthcare options.
If you choose to purchase private health insurance, there are different types of cover that offer different benefits. Generally, any medical services that Medicare covers and are listed under the MBS can also be covered to some degree by private health insurance.
Services that are not listed on the MBS, such as elective cosmetic surgery, are only covered by private health insurance to a limited extent or may not be covered at all. Your private health fund will only cover the procedure if:
- You have the right level of cover
- You meet the current Medicare eligibility criteria for MBS item 30175
- You have served the waiting period
Any policy you buy will have limitations on what and when you can claim, so it is important to know the details of any policy you are considering. For many private health insurers, Gold level coverage is required to receive benefits for a postpartum tummy tuck.
How Does the Hospital Affect My Eligibility?
Private hospitals work with both Medicare and private insurers. This means that if you are eligible for a postpartum abdominoplasty, are privately insured and have your surgery in a private hospital, Medicare and your private insurer may both contribute to the total fees, leaving you with a smaller out-of-pocket expense.
Public hospitals are run and funded by State and Territory Governments. They are a separate system from Medicare and often have their own “elective surgery policies” which may or may not reflect what is included on the MBS. This could affect your access to postpartum abdominoplasty in a public hospital depending on the state or territory where your procedure takes place.
What If I Do Not Qualify?
If you do not satisfy the criteria for any of the options in the previous section, you may consider self-funding your surgery. The cost of having a tummy tuck performed by a Specialist Plastic Surgeon in Australia varies depending on your location, the experience and expertise of the surgeon, and various personal factors that influence the specifics of your surgery.
For more information and an accurate price, please contact the Pure Aesthetics team to schedule your consultation.
If surgery is not an option for you, you may look into alternatives for the treatment or management of your condition. These may include:
- GP management of your symptoms
- Physiotherapy programs tailored to your needs
- Exercise aimed at improving core stability and functionality
What Other Item Numbers Relate To Abdominoplasty?
It is not only postpartum patients who can benefit from abdominoplasty. People who have achieved significant weight loss can also experience symptoms that make abdominoplasty a medically necessary procedure that qualifies for Medicare coverage. The MBS item number for this procedure is 30177.
Item 30177 applies to:
Lipectomy, excision of skin and subcutaneous tissue associated with redundant abdominal skin and fat that is a direct consequence of significant weight loss, in conjunction with a radical abdominoplasty (Pitanguy type or similar), with or without repair of musculoaponeurotic layer and transposition of umbilicus.
All of the following conditions must be met to qualify for this item:
- You have intertrigo or another skin condition that risks loss of skin integrity and has failed three months of nonsurgical treatment
- Your redundant skin and fat interferes with the activities of daily living
- Your weight has been stable for at least six months following your significant weight loss
What Are My Next Steps If I Am Interested in Postpartum Abdominoplasty?
At Pure Aesthetics, we know that surgery is a deeply personal and important decision, and we strive to ensure you feel informed and comfortable at every stage of your care. Our focus is on educating you so that you feel well-equipped to make the best choices for your treatment.
If you are considering a postpartum tummy tuck, these are some steps you can take to prepare:
- Visit our abdominoplasty page for more information about the procedure
- Dive deeper into the details of tummy tuck surgery on our blog
- Try to treat or manage your symptoms with nonsurgical measures like physiotherapy
- Look into your private health insurance options if you do not currently have a policy
- If you have private health insurance already, contact your insurer to determine the details of your policy
- Obtain a referral from your GP
- Book a consultation with a Specialist Plastic Surgeon
Start Your Tummy Tuck Journey at Pure Aesthetics
Postpartum tummies come in all shapes and sizes, but some are left with weakened muscles that can significantly diminish a woman’s quality of life. A Medicare-approved tummy tuck procedure can help you regain strength, stability and function if your abdominal muscles have been compromised by pregnancy.
To find out more about tummy tuck surgery in Sydney, call Pure Aesthetics today on 02 9252 9262 or request a consultation with us here.