Medicare for Diastasis Recti Repair Abdominoplasty

Split Tummy Muscles – Medicare for Diastasis Recti Repair in Australia – MBS Item Number 30175

Medicare Australia is designed to provide affordable and accessible healthcare services to all Australian citizens. It covers a wide range of medical procedures, including primary care, specialist consultations, diagnostic tests, and surgeries. However, understanding the ins and outs of Medicare can be challenging, especially when it comes to specific procedures like diastasis recti repair. In this blog, we will discuss diastasis recti repair, its Medicare coverage, eligibility requirements, out-of-pocket costs, and other financial assistance options

Dr Carmen Munteanu is a specialist plastic surgeon based in Melbourne well-known for her experience in body contouring procedures. She offers a range of procedures, including tummy tuck-abdominoplasty, liposuction, and body lift surgeries.

Download Dr Carmen’s Guide to Tummy Tuck Surgery – Abdominoplasty

What Is Diastasis Recti Repair?

Before discussing the Medicare coverage details, it’s essential to understand what diastasis recti repair is and why it might be necessary. Diastasis recti is a medical condition where the abdominal muscles separate, creating a gap between them. This separation can occur due to pregnancy, obesity, or other factors that put excessive pressure on the abdominal wall.

Diastasis recti repair, also known as abdominoplasty or tummy tuck, is a surgical procedure that aims to restore the normal position and function of the abdominal muscles. This is done by removing excess skin and fat, tightening the abdominal muscles, and suturing them together. The surgery can help improve the appearance of the abdomen, alleviate lower back pain, and enhance overall core stability.

Medicare Coverage for Diastasis Recti Repair

Beginning July 1, 2022, a new Medicare Benefits Schedule (MBS) item, 30175, was introduced, catering to patients requiring radical abdominoplasty combined with the repair of rectus diastasis, which is the separation of large abdominal muscles typically following pregnancy. This addition is specifically designed to help a niche group of patients who, before receiving this service, have been diagnosed with a diastasis of at least 3cm via diagnostic imaging. These patients typically experience moderate levels of discomfort or pain at the site of the diastasis on the abdominal wall during regular use. This discomfort may extend to lower back pain or urinary symptoms, particularly in cases where non-surgical conservative treatment, such as physiotherapy, has not provided effective relief.

Medicare Australia offers coverage for diastasis recti repair under specific circumstances. The procedure is listed under the Medicare Benefits Schedule (MBS) Item Number 30175, which covers “repair of diastasis recti or abdominal hernia (other than incisional).” However, not all cases of diastasis recti repair are covered by Medicare, and certain eligibility criteria must be met.

Medicare Benefits Schedule – Item 30175

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

(a) the patient:
(i) has a diastasis of at least 3cm measured by diagnostic imaging prior to this service; and
(ii) 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
(iii) has failed to respond to non-surgical conservative treatment including physiotherapy; and
(iv) has not been pregnant in the last 12 months

(b)    the service is not a service associated with a service to which item 30166, 30169, 30176, 30177, 30179, 30651, 30655, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies

Applicable once per lifetime

Eligibility and Requirements

To qualify for Medicare coverage under MBS Item Number 30175, you must meet the following eligibility criteria:

• Severity: The diastasis recti must be causing significant functional impairment, such as severe back pain or difficulty performing daily activities. Cosmetic concerns alone are not sufficient for Medicare coverage
• Conservative treatments: You must have tried and failed non surgical conservative treatments, that must include physiotherapy before surgery is considered
• Surgeon’s qualifications: The procedure must be performed by a registered specialist plastic or general surgeon who is recognised by Medicare Australia

Costs Associated with Getting an Abdominoplasty Surgery

Even if your diastasis recti repair is covered by Medicare Australia, you will still have to cover some costs. These can include:

• Surgeon’s fees: Medicare will only cover a portion of the surgeon’s fees, and you will be responsible for paying the remaining amount
• Anaesthetist fees: Medicare does not cover the full cost of anaesthesia, and you will need to pay the difference
• Hospital fees: If you choose to have your surgery in a private hospital, you will be responsible for those fees as Medicare will not cover a private hospital stay
• Post-surgery care: Medicare may not cover the full cost of post-surgery care, such as medications, dressings, or follow-up consultations

Private Health Insurance and Diastasis Recti Repair

If you have private health insurance, it may provide additional coverage for your diastasis recti repair surgery. Depending on your policy, private health insurance may cover:

• Hospital fees: Private health insurance can help cover the cost of a private hospital stay, reducing your out-of-pocket expenses
• Extras: Some policies may also cover additional services, such as physiotherapy or post-surgery care, which may not be fully covered by Medicare

Before scheduling your surgery, consult your private health insurance provider to discuss your coverage options and any limitations or exclusions that may apply.

Other Options to Finance Your Surgery

If you’re struggling to afford the out-of-pocket costs associated with diastasis recti repair surgery, there are additional financial assistance options available:

• Superannuation: In certain circumstances, you may be able to access your superannuation funds early to help cover the cost of your surgery. Consult the Australian Taxation Office for more information on this option
• Financial counselling: If you’re experiencing financial hardship, consider seeking advice from a financial counsellor who can help you assess your options and create a budget plan

Preparing For Diastasis Recti Repair Surgery

Once you have consulted with and chosen a Plastic and Reconstructive Surgeon and you’ve made arrangements for your out-of-pocket expenses, it’s time to prepare for your diastasis recti repair surgery. This may involve:

• Pre-surgery tests: Your surgeon may require you to undergo additional tests, such as blood work or imaging studies, to ensure you’re in good health before surgery
• Lifestyle changes: In the weeks leading up to your surgery, you may need to make some lifestyle changes, such as quitting smoking/vaping, losing weight, or improving your overall fitness
• Planning for recovery: Ensure you are prepared for your recovery, which may involve taking time off work, arranging for childcare, or having someone available to assist with daily tasks in the first few days post-op.

Navigating Medicare Australia for diastasis recti repair coverage can be a complex process, but with the right information and guidance, you can make informed decisions about your surgery.

For more information on Medicare Australia and diastasis recti repair coverage, consult the following resources:

• Medicare Benefits Schedule (MBS) Online: Access the MBS Item Number 30175 and other Medicare-covered services
• Australian Government Department of Human Services: Find information on Medicare services, benefits, and claims
• Private Health Insurance Ombudsman: Get advice on private health insurance coverage and resolving disputes with your insurer

FAQs about Medicare and Diastasis Recti Repair

What is Diastasis Recti Repair Surgery and is it covered by Medicare Australia?

• Diastasis Recti Repair Surgery is a surgical procedure to correct the separation of large abdominal muscles, a condition often resulting from pregnancy called diastasis recti. As of July 1, 2022, Medicare Australia introduced a new item (30175) which covers this procedure for qualifying patients.

Who qualifies for Medicare coverage for Diastasis Recti Repair Surgery?

• Medicare provides coverage for individuals who have a diastasis of at least 3cm as measured by diagnostic imaging prior to the surgery, and who experience moderate discomfort or pain at the site of the diastasis during functional use, lower back pain or urinary symptoms, especially if non-surgical conservative treatments such as physiotherapy have been ineffective.

What is the Medicare Benefits Schedule (MBS) item 30175?

• MBS item 30175 pertains to radical abdominoplasty combined with the repair of rectus diastasis (separation of large abdominal muscles), particularly following pregnancy.

How much of the cost for Diastasis Recti Repair Surgery does Medicare Australia cover?

• The amount Medicare covers for the surgery can vary based on individual circumstances and the specifics of your health insurance plan. It’s best to consult directly with Medicare or your health insurance provider for accurate information regarding coverage and out-of-pocket costs.

What is the process for claiming Medicare benefits for Diastasis Recti Repair Surgery?

• Once your surgery has been completed and you have received receipts from your surgeon and anaesthetist, you can submit a claim to Medicare. To do so, you’ll need to provide the appropriate documentation, including the MBS item number (30175 in this case).

Further Reading about Plastic Surgery with Dr Carmen

• Read Dr Carmen’s Preparing for Surgery Page
• Read Dr Carmen’s Tummy Tuck- Abdominoplasty Surgery Page
• See Dr Carmen’s Before and After Abdominoplasty Photo Gallery
• Read Dr Carmen’s Recovery after Tummy Tuck – Tips, Timeline and FAQs after Abdominoplasty Blog
• Read Dr Carmen’s Extended Tummy Tuck FAQs – Questions about Extended Abdominoplasty Blog
• Read Dr Carmen’s Blog about When Can I Exercise after Abdominoplasty Surgery

Medical References about Diastasis Recti

• Diastasis Recti (Abdominal Separation): Symptoms & Treatment
• Abdominal Separation (Diastasis Recti) – WebMD
• Diastasis Recti Rehabilitation – StatPearls – NCBI Bookshelf
• Surgical repair of diastasis recti abdominis provides long-term improvement of abdominal core function and quality of life: a 3-year follow-up