Can I Claim My Abdominoplasty on Medicare?

Patients always ask, ‘Will Medicare pay for my abdominoplasty 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, may be relieved by abdominoplasty surgery. So will it be covered? The answer depends on whether you meet the special criteria and conditions.

Dr Craig Rubinstein is an experienced plastic surgeon in Australia, and he has performed thousands of abdominoplasty surgeries with and without muscle repair throughout the years.

URGENT UPDATE – The Australian Government has reinstated a Medicare Item Number for abdominoplasty for some post-pregnancy patients suffering from Diastasis Recti (split abdominal muscles) if you are eligible and meet the new criteria. This new 30175 Medicare Item Number – is effective 1st July 2022. Read the 30175 Medicare Item Number factsheet.

If you qualify for the 30175 Medicare item number you may also get a subsidy from your Health Fund. There will still be a significant out-of-pocket GAP as abdominoplasty surgery is NOT FREE.

How Do You Qualify for Medicare Rebate for Abdominoplasty Surgery?

To qualify for a rebate from Medicare you will need to meet certain Medicare criteria for Abdominoplasty Surgery. Your eligibility may depend on assessing your medical condition.

You can also liaise directly with your chosen health fund regarding funding contributions for surgery to see if you are eligible.

These MBS Codes may be applicable for abdominoplasty:

30172 Lipectomy – multiple wedges of skin removal after Weight loss
31075 Radical Abdominoplasty with repair of diastasis recti following pregnancy
30177 Lipectomy, Post Weight loss (Abdominoplasty)
30179 Circumferential lipectomy (Belt lipectomy) – used for massive weight loss and excess skin removal

Full MBS Item Number Description

30172 Lipectomy, wedge excision of redundant non-abdominal skin and fat that is a direct consequence of significant weight loss, not being a service associated with a service to which item 30165, 30168, 30171, 30176, 30177, 30179, 45530, 45564 or 45565 applies, if:(a) there is intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non-surgical) treatment; and (b) the redundant skin and fat interferes with the activities of daily living; and (c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy; and (d) the procedure involves 3 or more excisions (H) (Anaes.) (Assist.)

30175 Radical abdominoplasty, with the repair of rectus diastasis, excision of skin and subcutaneous tissue, and transposition of the umbilicus, not being a laparoscopic procedure, where the patient has an abdominal wall defect as a consequence of pregnancy, if the patient:

has a diastasis of at least 3cm measured by diagnostic imaging prior to this service; and
has symptoms of at least moderate severity of pain or discomfort at the site of the diastasis in the abdominal wall during functional use and/or low back pain or urinary symptoms likely due to rectus diastasis that have been documented in the patient’s records by the practitioner providing this service; and
has failed to respond to non-surgical conservative treatment including physiotherapy; and
has not been pregnant in the last 12 months

The service is not a service associated with a service to which item 30165, 30651, 30655, 30168, 30171, 30172, 30176, 30177, 30179, 45530, 45564 or 45565 applies.

Applicable once per lifetime.

30177 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 the umbilicus, not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30176, 30179, 45530, 45564 or 45565 applies, if: (a) there is intertrigo or another skin condition that risks the loss of skin integrity and has failed 3 months of conventional (or non-surgical) treatment; and (b) the redundant skin and fat interferes with the activities of daily living; and (c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy

30179 Circumferential lipectomy, as an independent procedure, to correct circumferential excess of redundant skin and fat that is a direct consequence of significant weight loss, with or without a radical abdominoplasty (Pitanguy type or similar), not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30176, 30177, 45530, 45564 or 45565 applies, if: (a) the circumferential excess of redundant skin and fat is complicated by intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non-surgical) treatment; and (b) the circumferential excess of redundant skin and fat interferes with the activities of daily living; and (c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy (H).

DOWNLOAD GUIDE

Considering abdominoplasty surgery? Information is just one click away.

How to Research to See if Medicare and the MBS Cover 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 for your procedure, your health fund won’t cover the procedure either.

What to Expect When Claiming an Abdominoplasty Medicare Rebate & Private Health Fund Subsidy:

There will be a lot of paperwork if you are eligible for a rebate
Criteria are 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 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’ – there will be a GAP.

Some out-of-pocket expenses can be significant for customised expert procedures from an experienced plastic surgeon with FRACS.

Permanent Abdominal Bulge and Diastasis Recti After Pregnancy

Up to 2 in 3 women, potentially nearly all women, have separated abdominal muscles. 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.

This correction of separated abdominal muscles can be performed as part of a skin reduction/abdominal muscle repair procedure known as an abdominoplasty (often with suction-assisted liposuction).

The 30175 item number is suitable for a small subset of patients who have a diastasis of at least 3cm measured by diagnostic imaging prior to this service with moderate severity of pain or discomfort at the site of the diastasis in the abdominal wall during functional use and/or lower back pain or urinary symptoms and who have failed to respond to non-surgical conservative treatment, including physiotherapy.

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Abdominoplasty Before and After Photos

Abdominoplasty Surgery is a procedure that can help restore the look of your stomach after pregnancy or significant weight loss. This includes addressing excess skin and the abdominal ‘pouch’.

Gallery

Abdominoplasty Medicare Code Confusion

Changes to Medicare rebate structures for plastic surgery with functional benefits vs primarily cosmetic benefits remain confusing to patients. 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 the need for a Medicare rebate – you must meet the criteria. Post-weight loss, if you meet strict criteria, might attract a Medicare code for redundant skin reduction.

Criteria for post-weight loss patients are strict and include patient obesity versus weight change differences (BMI changes) and skin conditions.

Patients need to be aware the Medicare coding system is in a state of review and change. Read the ASAPS research indicating the functional benefits of abdominoplasty after pregnancy, and their call for the government to change abdominoplasty surgery coverage for women’s health after pregnancy.

Medicare Rebate & Health Fund 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, 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.

Some concerns and medical conditions after pregnancy include:

Core strength reduction from separated abdominal muscles
Constipation or low back pain caused by separated recti abdominous
Layered 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 over the beltline
Descended breasts that cause neck or back pain
Deflated-looking breasts and nipples (breast lift after pregnancy may be eligible for a Medicare rebate if strict criteria are met)
Skin infections caused by excess skin, such as rashes under the breast area or under the hanging skin after pregnancy

Medical Necessity vs Cosmetic Procedures and Medicare Rebates

A valid medical reason for surgery 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 descending 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.

Disclaimer: This information is general in nature. Its only intent is to give you a general overview of the Medicare system.

Send an enquiry form to get started on your post-pregnancy corrective plastic surgery procedures, or phone a Patient Care Coordinator on (03) 8849 1400.

About Dr Craig Rubinstein
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Dr Craig Rubinstein FRACS (Fellow of the Royal Australasian College of Surgeons) is an experienced Melbourne Specialist Plastic Surgeon for breast and abdominoplasty surgery.

Dr Rubinstein offers women personalised abdominoplasty surgery and all forms of cosmetic breast surgery.

BOOK A CONSULTATION (03) 8849 1400

Next Steps in Your Surgical Journey

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Want more information about your Procedure?

Download a Free Procedure Guide on your chosen surgery.
Visit the FAQs and read patient reviews to learn more about your intended procedure.
For more information about pricing visit our cost page.
You can also talk to our Patient Care Team from 9 to 5 pm Monday to Friday on (03) 8849 1400

About Your First Consultation

Dr Rubinstein’s Consultation fee is $300.
A referral from your GP or specialist is essential.
A referral helps when claiming Medicare or Private Health Insurance coverage.
Please contact the Patient Care Team at Coco Ruby Plastic Surgery to book your consultation.

Dr-Rubinstein-First-Consultation-Melbourne-plastic-surgeon

What to Bring to Your Consultation

You are more than welcome to bring a friend or relative to help discuss the information and your choices.
Ensure you also take a lot of notes and thoroughly examine the documents provided.
Please be aware you may need to undress for a physical exam so wear simple clothes.