Can I Claim Tummy Tuck (Abdominal) Surgery on Medicare?

Abdominal surgery also known as tummy tuck, abdominoplasty, apronectomy and is commonly requested by men and women of all ages following significant weight loss and by women after multiple pregnancies.

The type of abdominal surgery you require will depend on if your problem is:

• Problems of excess skin and/or fat on the abdomen and splitting (divarication) of the abdominal muscle (rectus abdominus) following pregnancy.
• Above and below, or just below the belly button (umbilicus).
• Simply a hanging “apron” of skin and fat in the lower abdomen.

The types of abdominal surgery are:

• Abdominoplasty, or a full tummy tuck, with or without plication (sewing together) of the rectus abdominus (abdominal muscles).
• Mini-abdominoplasty or mini tummy tuck if the problem is excess skin and fat in the lower abdomen only.
• Apronectomy if the problem is just an apron of skin in the lower tummy.

Will Medicare cover some of the costs of abdominal surgery?

There are three instances where Medicare will deem your surgery Medicare eligible and contribute towards the costs of your surgery.

Item number 30175

The first is for women requiring a full abdominoplasty to address significant muscle separation following pregnancy and who have had problems of back pain and/or urinary incontinence as a result of this weakness in the abdominal wall.

The Medicare guidelines state that:

• A separation of at least 3cm of the muscle wall must be verified by an ultrasound.
• Symptoms of moderately severe pain or discomfort at the site of the muscle separation during physical activities have been documented by the treating physician.
• The symptoms of urinary incontinence and/or lower back pain, likely due to the muscle separation have been unsuccessfully treated by non-surgical measures including physiotherapy.This information must be documented by the treating physician.
• You must not be pregnant within the last 12 months.

Item number 30177

The second is for an abdominoplasty (full tummy tuck) for men and women who have experienced Significant Weight Loss and are experiencing problems associated with the excess skin remaining.

The Medicare guidelines state that:

• The problem must be as a consequence of significant weight loss of 5 BMI (Body Mass Index) points or more.
  See below for an explanation of BMI.
• The weight has been stable for at least 6 months prior to the abdominal surgery.
• Problems of intertrigo (a rash under the skin fold) or other problematic skin conditions caused by the excess skin must be present.
• The redundant (spare) skin and fat interferes with your day to day living.

Item number 30165

The third is for men and women experiencing functional problems as a direct consequence of an overhanging “apron” of skin resulting from significant weight loss.

The Medicare guidelines state:

• The problem must be as a consequence of significant weight loss of 5 BMI (Body Mass Index) points or more. See below for an explanation of BMI.
• The weight has been stable for at least 6 months prior to the abdominal surgery.

NB There are no rebates available for a min-abdominoplasty at this stage. This surgery is classified “cosmetic”.

BMI or Body Mass Index

• BMI is a measure of body fat based on your height and weight.
• There are many BMI calculators available on the internet. You simply insert your height and your weight, and the web tool will give you a reading.
• A BMI of 20 – 25 is considered a healthy weight range.
• Dr McGovern, after years of experience wants you to have a BMI of 27 or less before embarking on surgery to reduce the risks of the anaesthetic and complications following surgery, including but not limited to problems of wound healing.
• All problems associated with surgery are increased dramatically as your BMI increases.

Will private health insurance cover the costs of abdominoplasty/ abdominal surgery?

• You must have an adequate level of cover with your health fund. See explanation below.
• In general, if Medicare pays (if you are within the strict Medicare guidelines), your health fund should pay.
• This does not mean that they will cover all of your costs, but they should contribute significantly to your hospital fees. See below for more information on private health insurance contributions.

What type of cover do I need with my private health insurer to cover some of my abdominal surgery fees?

• Your policy must include private hospital cover.
• You must not have chosen to exclude plastic surgery item numbers from your policy.

How do I check if my health insurance will cover some of the costs of my abdominal surgery?

• You will need to call your insurer with the item number provided by Dr McGovern’s staff.
• This will be provided after consultation and examination with Dr McGovern.
• If your circumstances are not within the strict Medicare guidelines, you will not be able to use the Medicare Item numbers and your surgery will be deemed cosmetic. See below for further explanation.

What will Medicare and my health insurance cover for abdominoplasty/ apronectomy?

• If you are within Medicare guidelines, and your health insurance cover is adequate to cover this surgery, your health insurance should cover your hospital fees, less any excess that you have agreed upon.
• Medicare and your health fund will rebate a portion of Dr McGovern’s fees and your anaesthetic fees.
• Dr McGovern’s staff can provide you with Medicare rebate information for the surgery you require.
• The Sunshine Coast Anaesthetic Group should supply you with Medicare rebates for their fees,
• Your health insurer will be able to provide information on their rebates amounts.
• All rebates are claimed on or after your date of surgery.

How will the costs for abdominal surgery differ if I am not within the Medicare Guidelines for abdominoplasty/ apronectomy?

• If you are not within the Medicare guidelines, your surgery will be deemed “cosmetic”.
• In this case GST is payable on all fees: hospital fees, anaesthetic fees and surgeon’s fees.
• There are no rebates from Medicare or health insurance if your surgery is deemed cosmetic.
• If you would like more information on your particular circumstance, our cosmetic consultant, Katherine (an RN that has worked with Dr McGovern for 29 years) is happy to chat with you and help you with this information.

Dr McGovern offers a service whereby after speaking with our cosmetic consultant, you can send along photos for him to review and give his opinion on the surgery you may require. We can then give you accurate information on the surgery and the costs involved, before making an appointment to see Dr McGovern.

We are here to help you achieve your goals.