Can I Claim my Abdominoplasty Surgery on Medicare?
Patients always ask, “will Medicare cover my Tummy Tuck surgery?” There is significant research that indicates women’s health and post-pregnancy conditions, such as lower back pain, muscle separation (diastasis recti) and incontinence, can be greatly relieved by abdominoplasty surgery. So will it be covered? The answer is MAYBE – IF you meet the special criteria.
Permanent Abdominal Bulge and Diastasis Recti After Pregnancy
You’re not alone. Up to 2 in 3 women, potentially nearly all women, have separated abdominal muscles and chronic belly bulges after pregnancy.
Exercise and nutrition are a good start to getting your body back in shape. But if the muscles of your abdomen are torn and remain separate at 12 months after pregnancy, diastasis recti will often require surgical correction. It is not likely to resolve further on its own accord.
Will Medicare Cover Tummy Tuck Surgery after Pregnancy?
At the moment, Medicare does NOT cover post-pregnancy abdominoplasty procedures. This is true, even when the procedure warrants medical intervention. Some patients who have lost a LOT of weight and have redundant SKIN FOLDS MAY be eligible for a rebate. Strict patient criteria and medical condition criteria must also be met to be eligible for any rebates.
Many women will not qualify for a rebate for tummy tuck after pregnancy, unless Medicare reinstates codes for abdominoplasty after pregnancy. There was Medicare coverage for corrective abdominoplasty after pregnancy, but this was removed from the rebate system a few years ago.
Medicare Code Confusion
Changes to Medicare rebate structures for plastic surgery with functional benefits vs primarily cosmetic benefits, remain confusing to patients. Further, the primary reason for Medicare code confusion is that the answer can vary from patient to patient.
Post-pregnancy problems on their own do not indicate a Medicare rebate. Post-weight loss, if you meet strict criteria, might attract a Medicare code for redundant skin reduction.
Patients need to be aware the Medicare coding system is in a state of constant flux. There are frequent changes, with little to zero advanced notice to patients, plastic surgeons and hospitals.
Read the ASAPS media release on research indicating functional benefits of abdominoplasty after pregnancy, and the call for government to change abdominoplasty surgery coverage for women’s health improvements after pregnancy.
Criteria for post-weight loss patients is strict and includes patient obesity versus weight change differences (BMI changes) and skin conditions.
Health Fund or Medicare Rebate Eligibility
Medicare will not cover most plastic surgeries, but some corrective plastic surgery procedures may be. For example, abdominoplasty after significant weight loss, meeting strict criteria, may attract a Medicare rebate or health fund coverage.
So, too, might a breast reduction or breast lift after pregnancy if the patient meets the strict Medicare rebate criteria and has moderate to severe breast ptosis.
Health fund policies are notoriously complex and include numerous disclaimers, exclusions and waiting periods. However, there have been changes in the industry to simplify policies into key plans, to help consumers choose their best health funds.
Some corrective plastic surgery procedures may have a Medicare rebate if you meet strict patient criteria and require a medically-necessary procedure.
Your GP and specialist may be able to ascertain if your requirements meet the strict Medicare rebate criteria for plastic surgery.
For patients who are concerned about Medicare rebates or surgery funding, it may be helpful to ascertain your current eligibility for coverage and to schedule procedures before any sudden further changes in Medicare or health fund policies.
It may also help to explore super for surgery for select cases of surgical need:
- Even Australian health funds may not always cover your surgery costs.
- Most health funds go public and primarily focus on generating stock holders returns, and higher profit margins, rather than patient reimbursement ratios
- Insurance companies even try to blame medical professionals for low rebates and high out of pocket costs, rather than their management teams
- They insist a surgeon or medical practitioner who spent over 2 to 3 decades achieving expertise and qualifications should accept a ‘no gap’ low rate fee
- Many argue this strategy of surgeon-blaming is an attempt to draw attention away from the fact the health fund managers are constantly reducing reimbursements and increasing surgery exclusions to improve their bottom line
- This likely results in large bonuses to the health insurance fund’s CEO and management staff but may be to the detriment of policy holders in some situations
Some concerns and medical conditions after pregnancy include:
- core strength reduction from separated abdominal muscles
- constipation or low back pain caused by separated recti abdominus
- sagging skin on the abdomen and a bulge (or hernia) in the abdominal area that prohibits exercise or good posture
- mild urinary incontinence caused by torn abdominal muscles (diastasis recti)
- excess, redundant stretched skin that hangs like an apron over the belt line
- sagging breasts that cause neck or back pain
- deflated looking breasts and nipples that sag (breast lift after pregnancy may be eligible for a Medicare rebate if strict criteria are met
- skin infections caused by sagging skin such as rashes under the breast area or under the hanging skin apron after pregnancy
What to expect:
- There will be a lot of paperwork if you are eligible for a rebate
- Criteria is very strict and you may not meet eligibility criteria
- You will still have out of pocket expenses
- Some health funds cover some hospitalisation costs (not all), but there is no guarantee
- Each fund and coverage plan is unique – call your fund, investigate others, and do research the current MBS online criteria for Medicare Rebate eligibility
- You will probably spend hours on the phone speaking with your insurance company/private health fund to assess what they will or won’t cover so you can work out your budget and payment methods
- Some patients then apply for early release of superannuation
Tip: “fully covered” from an insurance fund rarely means ‘completely covered’.
Some out of pocket expenses can be significant for customised-expert procedures from an experienced plastic surgeon with FRACS. Publicly-traded health funds may be more interested in serving their investors than their patients. As a result, choose your health fund wisely.
Medical Necessity vs Cosmetic Procedures and Medicare Rebates
A valid medical reason for surgery and which might attract a minor surgery rebate from Medicare and/or a health fund may include things like:
- Facial reconstructive surgery after an accident
- Rhinoplasty (corrective nose surgery/nasal area reshaping) to rectify nasal passage obstruction where nose injury or other nasal structural abnormality impairs breathing
- Plastic surgery following skin cancer removal
- Hand surgery
- Damaged abdominal areas after pregnancy or C-section delivery (specific criteria apply)
- Breast reconstruction following a mastectomy or other breast cancer treatments
- Surgery following rapid weight loss:
- surgical excision and reduction of excess, loose skin or redundant tissue folds including through abdominoplasty, belt lipectomy or similar procedures
- Eyelid lift surgery where sagging upper eyelid skin impedes vision
- Breast lift or breast reduction surgery may occasionally be eligible for minor Medicare rebates for patients meeting very specific criteria, including:
- severe breast ptosis
- recurring health problems related to the size, position or skin condition of your breast area
- The best way to find out about your cover is to chat with a medical professional
- Ask for a referral for a consultation with Dr Rubinstein
You can often schedule a no-obligation consultation without a Medicare referral. However, for any potential Medicare rebates for corrective surgery, a referral before your consultation is absolutely necessary.
Lobbying Medicare for Change
There is ongoing lobbying for more government support of women’s health and post-pregnancy surgery procedures. This includes reducing low back pain and diastasis recti related-problems including urinary incontinence after pregnancy.
Many women’s health groups are currently advocating for changes to be made to the Medicare coding system given research shows the functional benefits of abdominoplasty after pregnancy would be in the interest of family health, women’s health and public health.
How to Research to See if MBS Covers Your Surgery Procedure
- The MBS is a very comprehensive list, which can be downloaded in its entirety.
- Alternatively, you can just use the search function to find your procedure.
- Further, if there is no valid Medicare code to your procedure, your health fund won’t cover the procedure either.
Disclaimer: This information is general in nature. It’s only intent is to give you a general overview of the Medicare system.
Send an enquiry form today to get started on your post-pregnancy corrective plastic surgery procedures, or phone a Patient Care Coordinator on (03) 8849 1444.
Benjamin, D.R.; Van de Water, A.T.M; Peiris, C.L. (March 2014). “Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review”. Physiotherapy. 100 (1): 1–8. doi:10.1016/j.physio.2013.08.005. PMID 24268942.
Please Contact Dr.Rubinstein’s office to book a consultation or enquire about further information regarding plastic surgery procedures.
Dr. Craig Rubinstein’s affiliations include: