Will Medicare Cover My Tummy Tuck – Abdominoplasty?

UPDATED Medicare Item Numbers for Abdominoplasty in Melbourne

Medicare provides a wide range of health services—from hospital care to pharmaceutical subsidies. Its primary aim is to offer affordable and accessible medical care to every Australian citizen. In this context, understanding the policies and procedures of Medicare becomes essential.

This knowledge helps you to make informed decisions about your healthcare needs and assess the financial implications of any medical procedure, including abdominoplasty, more commonly known as a tummy tuck, and whether or not it is covered by Medicare.

Plastic surgeries, especially surgeries with some cosmetic benefit, often fall into a grey area when it comes to Medicare coverage. Procedures like abdominoplasty are not covered unless they’re deemed medically necessary. In this blog, we will answer this popular question “Will Medicare cover my abdominoplasty?”

When considering a procedure like abdominoplasty, it’s crucial to consult with an experienced and reputable surgeon. In Melbourne, one such surgeon is Dr Carmen Munteanu. With her team, she provides a range of cosmetic and reconstructive procedures, including tummy tucks – abdominoplasties.

Dr Munteanu is a specialist plastic and cosmetic surgeon with a focus on patient safety, satisfaction, and meticulous attention to detail. Her philosophy is to provide individualised care and a tailored approach to each patient, ensuring optimal outcomes. Her team is well-versed in the complexities of Medicare’s policies and offers guidance on the coverage of different procedures, including abdominoplasty.

UPDATEMedicare Item Numbers have changed – effective 1st July 2023 – Item Numbers 30165, 30168, 30171 and 30172 have been deleted. 30166 & 30176 have been added. NEW Combination Surgeries are possible – 30166 (Abdo) can now be combined with 30169 (Arms/legs).

PLEASE NOTE – FREE Abdominoplasty Surgery is rarely available in the Australian Public System and has a very long waiting list. A substantial Out-of-Pocket Fee is required for abdominoplasty surgery with a Plastic Surgeon in private practice – even with a subsidy from Medicare and your Health Fund.

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

GUIDE Tummy Tuck
 

What Is Abdominoplasty?

Abdominoplasty, also known as a tummy tuck, is a surgical procedure that involves removing excess fat and skin from the abdomen to create a smoother and firmer profile. It’s often sought after by individuals who have undergone significant weight loss, pregnancy, or ageing, leading to a sagging abdomen.

This procedure is not a substitute for weight loss or an exercise program. It’s best suited for individuals who are in good health but are bothered by a large fat deposit or loose abdominal skin that doesn’t respond to diet or exercise. The results of an abdominoplasty are technically permanent, but the positive outcome can be greatly diminished by significant fluctuations in your weight.

While abdominoplasty can enhance your appearance, it’s important to consider the financial implications. Understanding whether Medicare covers the procedure is a critical part of your decision-making process.

Criteria for Abdominoplasty Coverage under Medicare

Medicare provides coverage for abdominoplasty only under specific circumstances – if you meet all of the strict criteria (See below). Medicare does NOT cover your surgery if it’s solely for cosmetic purposes. However, if the procedure is deemed medically necessary, it may be covered by Medicare.

If your abdominoplasty surgery is deemed to be covered by Medicare, then you may be eligible for a subsidy from your Health Insurance Fund if you have the right level of cover (please check with your Health Fund).

PLEASE NOTE – Even with Medicare coverage and a subsidy from your Private Health Insurance, there will still be a substantial Out-of-pocket cost to have surgery with a Plastic Surgeon in private practice. There is a very long waiting list to have Abdominoplasty in the Public System as it is not a priority surgery.

The strict criteria for Medicare coverage (see below for details) includes conditions like significant weight loss resulting in excess, hanging skin that causes physical discomfort or health issues, such as rashes or skin infections. Abdominoplasty following pregnancy may also be covered, provided it’s causing physical complications.

It’s crucial to consult with your plastic surgeon and discuss your medical history and current health status to understand whether you qualify for Medicare coverage.

Abdominoplasty Medicare Item Numbers (in Detail)

Medicare uses specific item numbers for each medical service. For abdominoplasty, the relevant Medicare item numbers are 30166, 30175, 30176, 30177, and 30179.

More details about each Tummy Tuck/ Abdominoplasty Medicare Item Number from MBS Online site:

Medicare Item Number 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  30166, 30175, 30176, 30179, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies, if:

  • 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
  • the redundant skin and fat interferes with the activities of daily living; and
  • the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy

Medicare Item Number 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:

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

 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

Medicare Item Number 30166

Removal of redundant abdominal skin and lipectomy, as a wedge excision, for functional problems following significant weight loss equivalent to at least 5 body mass index points and if there has been a stable weight for a period of at least 6 months prior to surgery, other than a service associated with a service to which item 30175, 30176, 30177, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies (H)

Medicare Item Number 30176

Radical abdominoplasty, with excision of skin and subcutaneous tissue, repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30166, 30169, 30175, 30177, 30179, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070 or 46072 applies, if the patient has previously had a massive intra-abdominal or pelvic tumour surgically removed (H)

Medicare Item Number 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 30175, 30176, 30177, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 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

The Cost of Abdominoplasty in Melbourne – Tummy Tuck Prices

The cost of abdominoplasty in Melbourne can vary significantly depending on various factors, including the surgeon’s experience and the complexity of the procedure. On average, you can expect to pay $15,000 to $24,000 for a tummy tuck – abdominoplasty. This estimate includes the surgeon’s fee, anaesthesia, hospital or surgical facility costs, medical tests, post-surgery garments, and prescriptions for medication.

While the cost may seem high, it’s important to remember that choosing a qualified and experienced surgeon like Dr Munteanu can ensure a safer procedure with better results. Furthermore, the cost should not be the only deciding factor; the surgeon’s experience, the quality of care, and the potential for achieving your desired results should also be considered.

Understanding the criteria for abdominoplasty coverage under Medicare can potentially alleviate some of the financial burdens associated with this procedure.

Private Health Insurance Coverage for Tummy Tucks

While Medicare may provide some coverage for abdominoplasty, private health insurance can also play a role in managing the costs. Many private health insurance policies offer coverage for plastic and reconstructive surgery when it’s medically necessary.

It’s important to review your insurance policy and speak with your insurer to understand what is covered. Remember to ask about any waiting periods, exclusions, and out-of-pocket costs.

Using Your Super Fund for Abdominoplasty

In certain circumstances, you may be able to access your super fund to cover the costs of your abdominoplasty. This is generally possible when you can demonstrate that the procedure is a necessary part of treating a medical condition or improving your quality of life.

It’s important to speak with a financial advisor or your super fund provider to understand the implications of this decision and the process involved.

FAQ Plastic Surgery

FAQs about Medicare and Abdominoplasty

What is Medicare’s policy on covering abdominoplasty (tummy tuck) procedures?

  • Medicare does provide coverage for abdominoplasty under certain conditions. If the procedure is medically necessary and not purely cosmetic, such as when it is needed after significant weight loss or following pregnancy, it may be covered. However, the specific criteria must be met, which usually requires a consultation with a plastic and reconstructive surgeon about your health condition.

What are the criteria that need to be met for Medicare to cover an abdominoplasty?

  • For Medicare to cover an abdominoplasty, the procedure must be deemed medically necessary. For instance, it can be necessary to rectify issues like back pain, skin infections, hernia or muscle separation that might occur after significant weight loss or pregnancy. Medicare requires proper documentation showing that non-surgical treatments have been unsuccessful in the case of muscle separation and the procedure is crucial for improving the patient’s health. Please consult with your doctor for detailed requirements as it can vary from case to case.

How can I initiate the claims process with Medicare for my abdominoplasty procedure?

  • Once the procedure is complete, you can submit a claim to Medicare either online, through the Medicare mobile app, by mail, or in person at a service centre. Be sure to keep all documents and receipts as they are required during the claim process.

How much of the abdominoplasty cost will Medicare cover?

  • The amount covered by Medicare varies depending on the specifics of your case and the Medicare Benefits Schedule (MBS) item number for the service provided. Medicare usually covers 75% of the MBS fee for specialists and 100% for GP services. However, this may not cover the total cost of the procedure, and you will likely have out-of-pocket expenses.

What out-of-pocket costs might I expect if I get an abdominoplasty?

  • Out-of-pocket costs can significantly vary depending on various factors like the surgeon’s fee, anaesthetist fee, hospital costs, pathology, and pharmacy costs. Medicare does not cover these additional costs, and they can amount to a substantial sum. It is essential to consult with your plastic surgeon to get an accurate estimate of the total cost and what portion Medicare will cover.

Further Reading about Body Contouring Procedures with Dr Carmen

Medical References about Abdominoplasty and Medicare

Further Reading about Body Procedures with Dr Carmen

Dr Carmen Munteanu – Specialist Plastic Surgeon

She is one of Melbourne’s most experienced and sought-after female Plastic Surgeons who offers aesthetic breast surgery and body contouring. That includes Breast Reduction, Breast Lift, Breast Implant Surgery and Body Surgery.

With over 25 years of surgical experience in Plastic Surgery, Dr Carmen firmly believes that a good surgeon is first a good doctor. She will always take into consideration all the health aspects and personal circumstances of each patient.

A dedicated Specialist Plastic and Cosmetic Surgeon, Dr Carmen is renowned for providing exceptional care, support and helping achieve realistic goals for her patients.

About Dr Carmen

What to do next

Conduct Research:

Get a Medical Referral before your consultation with Dr Carmen

  • A GP referral is now essential to see Dr Carmen for any type of surgery.

Making The Most Of Your Consultation

  • Please arrive slightly early for your in-person consultation with Dr Carmen – Car parking is available on-site in Mitcham.
  • You are welcome to bring a friend or relative to help consider the information and discuss your options.
  • Please be aware you may need to undress for a physical exam so wear simple clothes.
  • Photos will be taken as part of your consultation, please try and wear black underwear.
  • Ensure you also take a lot of notes during the consultation and thoroughly examine all the documents provided.

Want more information before scheduling your consultation?

How to Book your Consultation with Dr Carmen

  • You can book your consultation with Dr Carmen Munteanu by paying the $300 cosmetic consultation fee in advance – when you make your appointment.

‘Your Goal is my Priority’
– Dr Carmen Munteanu

M.D. FRACS(Plas) Plastic, Reconstructive and Cosmetic Surgeon

Contact Dr Carmen

Call 1300 652 468 to arrange your consultation or email us for more information. We look forward to hearing from you soon!

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