Will Medicare Cover my Abdominoplasty/ Tummy Tuck?

Dr Michael Kernohan MBBS, MSc, BDS, MRCS, FDSRCS, FRCS(Plast), FRACS (Plast

Medicare Coverage for Medically Necessary Abdominoplasty Procedure

You’ve probably heard of “tummy tuck,” medically known as Abdominoplasty, a surgical procedure designed to remove excess skin and fat from the abdomen, tightening the abdominal muscles. While some consider this procedure for purely aesthetic reasons, others may need it to address functional issues caused by excess skin and muscle separation. This leads to a common question: does Medicare cover Abdominoplasty?

In this blog post, Specialist Plastic Surgeon Dr Michael Kernohan will explore the circumstances under which Medicare may cover Abdominoplasty and what you can expect throughout the process.

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Medicare’s Stance on Abdominoplasty

Medicare’s stance on covering Abdominoplasty procedures is rooted in their fundamental purpose as a health insurance program. Medicare is designed to provide coverage for medical services and treatments that are considered necessary for maintaining or improving an individual’s health and overall well-being. This means that Medicare’s coverage decisions are based on medical necessity rather than cosmetic or aesthetic preferences.

In the case of Abdominoplasty, also known as a tummy tuck, Medicare generally views it as an elective cosmetic procedure. The primary goal of a tummy tuck – abdominoplasty is to alter the appearance of the abdominal area by removing excess skin and fat and tightening the abdominal muscles. The procedure is not usually considered essential for maintaining good health.

As a result, Medicare typically does not provide coverage for tummy tucks – abdominoplasty procedures when they are performed solely for cosmetic reasons. If an individual chooses to undergo abdominoplasty to achieve a flatter abdominal appearance without an underlying medical need, they will likely be responsible for the full cost of the procedure out-of-pocket.

However, it’s important to note that there are certain situations in which Medicare may consider covering abdominoplasty. These exceptions arise when the procedure is deemed medically necessary to treat a specific health issue or improve an individual’s functional abilities. For example, if excess abdominal skin is causing recurrent skin infections, rashes, or sores that do not respond to conservative treatments, Medicare may approve coverage for a tummy tuck – abdominoplasty to alleviate these medical concerns. Similarly, if abdominal muscles have become severely weakened or separated (a condition known as diastasis recti) and are causing significant pain, discomfort, or functional limitations, Medicare may consider covering abdominoplasty as part of a complex treatment plan.

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In these exceptional cases, a healthcare provider must provide thorough documentation demonstrating the medical necessity of the procedure. This documentation should include a detailed medical history, physical examination findings, and evidence that non-surgical treatments have been attempted and failed to resolve the underlying health issue.

Ultimately, Medicare’s decision to cover abdominoplasty is made on a case-by-case basis, taking into account an individual’s unique medical circumstances. While the vast majority of tummy tucks – abdominoplasty procedures are considered cosmetic and therefore ineligible for Medicare coverage, there are instances in which the procedure may be deemed medically necessary and covered accordingly. If you are considering abdominoplasty, you should consult with Dr Michael Kernohan to determine if your specific situation may qualify for Medicare coverage. Keep in mind that a GP referral is necessary to see Dr Kernohan if you want to get Medicare cover for your abdominoplasty surgery.

When Medicare Might Cover Abdominoplasty

While Medicare’s stance on cosmetic abdominoplasty is clear, there are exceptions. Let’s look at these instances:

  • Reconstruction After Significant Weight Loss: Individuals who have undergone substantial weight loss, often due to bariatric surgery, might experience significant excess skin in the abdominal area. This excess skin can lead to physical discomfort, rashes, and infections. In such cases, Medicare might cover abdominoplasty as a reconstructive surgery to address these health issues.
  • Repair of a Ventral Hernia: A ventral hernia occurs when abdominal tissue protrudes through a weakness in the abdominal wall. This condition can cause pain and complications. If you have a ventral hernia, Medicare might cover abdominoplasty as part of the hernia repair surgery.
  • Addressing Severe Functional Impairment: In rare cases, excess abdominal skin can cause significant functional impairment, affecting your mobility and daily activities. If your doctor can demonstrate that the excess skin severely restricts your movement and impacts your quality of life, Medicare might consider covering abdominoplasty.
  • Repair of Diastasis Recti: Muscle separation of more than 30mm, caused by pregnancy and documented by diagnostic imaging prior surgery. If you meet this criteria, Medicare might consider coverage to address this defect.

Medicare Item Numbers for Abdominoplasty

In Australia, medical procedures are assigned specific item numbers, which are used to identify and categorise treatments for billing and insurance purposes. In this case, the Medicare Item Number regarding Abdominoplasty – Tummy Tuck are:

·       Medicare Item Number 30166

Medicare Benefits Schedule Item 30166 pertains to the surgical removal of redundant abdominal skin and lipectomy as a wedge excision. This procedure is applicable for patients who have experienced significant weight loss, defined as a loss of at least five BMI points, and have maintained a stable weight for at least six months. It is specifically targeted at addressing functional issues, not cosmetic concerns, and cannot be claimed in conjunction with certain other MBS items related to post-mastectomy breast reconstruction or other specified procedures.

For more detailed information, you can visit the Medicare page.

·       Medicare Item Number 30175

Medicare Benefits Schedule Item 30175 covers radical abdominoplasty with repair of rectus diastasis, skin and subcutaneous tissue excision, and umbilicus transposition. It’s eligible for patients with abdominal defects due to pregnancy, exhibiting a diastasis of at least 3cm, experiencing significant discomfort or related symptoms, and who have not responded to non-surgical treatments like physiotherapy. This item cannot be claimed alongside specific other medical services, is limited to once per lifetime.

For further details, you can view the complete information directly on the Medicare page.

·       Medicare Item Number 30176

Medicare Benefits Schedule Item 30176 pertains to radical abdominoplasty, which involves the excision of skin and subcutaneous tissue, the repair of the musculoaponeurotic layer, and the transposition of the umbilicus. This specific item is applicable when the patient has previously undergone surgical removal of a massive intra-abdominal or pelvic tumour. This procedure is not to be claimed in conjunction with certain other specific Medicare items, particularly those related to post-mastectomy breast reconstruction or certain other abdominoplasty and lipectomy procedures.

For more detailed information, you can visit the Medicare page directly.

·       Medicare Item Number 30177

Medicare Benefits Schedule Item 30177 covers lipectomy combined with radical abdominoplasty, including skin and fat excision due to significant weight loss. This procedure is eligible when the patient has persistent skin conditions unresponsive to three months of non-surgical treatments and the redundant skin and fat interfere with daily activities. The patient’s weight must have been stable for at least six months following significant weight loss. This item can not be claimed with several other related MBS items.

For more detailed information, you can view the complete Medicare page here.

·       Medicare Item Number 30179

Medicare Benefits Schedule Item 30179 covers circumferential lipectomy, as an independent procedure or in combination with radical abdominoplasty. It addresses circumferential excess of redundant skin and fat resulting from significant weight loss. This procedure is applicable if associated skin conditions have not improved with three months of non-surgical treatment and if the excess skin and fat interfere with daily activities. The patient’s weight must have been stable for at least six months. This item cannot be claimed with several other related MBS items.

For more detailed information, you can visit the Medicare page.

Essential Criteria for Medicare Coverage

For Medicare to consider covering an abdominoplasty procedure, several essential criteria must be met. These criteria are designed to ensure that the surgery is being performed for legitimate medical reasons rather than solely for cosmetic purposes.

Medical Necessity

Your plastic surgeon must provide a compelling and well-documented notes demonstrating that the tummy tuck – abdominoplasty is necessary to address a specific health issue or functional impairment.

This goes beyond the desire for cosmetic improvement and requires evidence that the excess skin is causing significant problems such as:

  • Recurrent skin infections
  • Rashes or sores
  • Back pain due to weakened abdominal muscles

Your GP or plastic surgeon will need to document these issues thoroughly, detailing the severity of the problem and how it impacts your daily life and overall health.

Documentation

To support the case for medical necessity, your doctor will need to compile comprehensive documentation, including:

  • Your complete medical history, detailing any relevant health conditions, previous surgeries, and treatments you have undergone
  • If your need for a tummy tuck – abdominoplasty is related to significant weight loss: Documentation of your weight loss journey, including any bariatric surgery or medically supervised weight loss programs you have completed
  • If you have a hernia that requires repair in conjunction with the abdominoplasty: Details about the type and severity of the hernia and how it affects your health
  • In cases where excess skin is causing functional impairments: Clear evidence of these limitations, such as photographs or physical therapy evaluations

Meeting these essential criteria – establishing medical necessity and providing comprehensive documentation– is crucial to support your Medicare claim for your abdominoplasty procedure. By working closely with your GP and plastic surgeon, you can ensure your medically necessary abdominoplasty meets the criteria for Medicare coverage.

Understanding the Costs – Out of pocket expenses

Out-of-Pocket Costs

Even if Medicare covers your abdominoplasty, there will still be some out-of-pocket costs. These can include:

  • Gap Fees: This is the difference between what Medicare and your private health insurance (if you have it) cover and what the surgeon and hospital charge.
  • Hospital Fees: If the procedure is done in a private hospital, there may be hospital admission fees and other related costs.
  • Anaesthesia Costs: Fees for the anaesthetist will not be fully covered.
  • Follow-Up Visits: Some post-operative consultations and care might incur additional costs.

Public vs. Private

If the procedure is done in a public hospital, it might be covered by Medicare with minimal out-of-pocket costs. However, wait times can be long (many years). If done in a private setting, costs will be higher and subject to the terms of your private health insurance, if applicable.

Private Health Insurance

If you have private health insurance, it may cover additional costs not covered by Medicare, but you will need to check with your insurer regarding the specific coverage details and any applicable excess or co-payment.

FAQs about Medicare and Abdominoplasty

FAQs

Can abdominoplasty be covered if it is performed for purely cosmetic reasons?

  • No, Medicare does not cover abdominoplasty if it is performed for purely cosmetic reasons. Coverage is typically granted only when there are specific medical indications such as significant discomfort or functional impairment caused by excess skin.

Are there follow-up treatments after abdominoplasty that Medicare might cover?

  • Medicare may cover certain follow-up treatments if they are deemed medically necessary. This could include treatments for complications or additional surgeries to correct issues from the initial procedure.

Further Reading about Tummy Tuck – Abdominoplasty with Dr Michael Kernohan

Medical References about Tummy Tuck – Abdominoplasty