Abdominoplasty, commonly known as a tummy tuck, is a surgical procedure that removes excess skin and fat from the abdominal area while tightening the underlying muscles. This surgery not only enhances the aesthetic appearance of the abdomen but can also provide significant functional benefits, such as improved core strength and posture.
A frequent question we receive at Dr Turner’s clinic is whether Medicare covers the cost of an abdominoplasty surgery. The short answer is Yes, but only under specific medical conditions and criteria. In this article, Dr Turner, a Specialist Plastic Surgeon in Sydney, will discuss the eligibility requirements for abdominoplasty.
Why Do People Seek Abdominoplasty Surgery?
Many people consider tummy tuck surgery for various reasons:
Post-Pregnancy Changes: After pregnancy, the abdominal muscles can stretch or separate—a condition called diastasis recti. This can make the belly stick out and not return to its pre-pregnancy shape, no matter how much you diet or exercise. The skin on the abdomen might also have stretched so much that it doesn’t tighten back, leaving sagging skin, which can affect your posture, comfort, and ability to exercise.
Massive Weight Loss: Losing a significant amount of weight is a great accomplishment. However, it can sometimes leave you with loose, sagging skin around your abdomen. This isn’t just about appearance—it can be uncomfortable, make it hard to find clothes that fit well, and even lead to hygiene problems like skin irritation or infections.
Cosmetic Improvement: Sometimes, even with a healthy diet and regular exercise, you might still have a bit of a tummy that won’t go away. Factors like aging, genetics, or previous surgeries can contribute to this stubborn area. If you’re aiming for a flatter abdominal appearance, an abdominoplasty can help.
Does Medicare Cover Abdominoplasty?
Medicare in Australia covers medical procedures deemed medically necessary. Abdominoplasty is typically considered a cosmetic procedure and is not routinely covered by Medicare, except under specific circumstances where the surgery addresses significant medical conditions.
To qualify for Medicare coverage, the abdominoplasty must meet strict criteria outlined in the Medicare Benefits Schedule (MBS):
- Significant Weight Loss: The patient has lost at least 5 BMI units and has maintained a stable weight for at least six months.
- Post-Pregnancy Patients: Must wait at least 12 months after childbirth before undergoing surgery.
- Health Complications Caused by Excess Skin:
- Chronic Skin Conditions: If you’re dealing with a skin condition like intertrigo—a rash that develops in skin folds—that hasn’t improved after three months of non-surgical treatments.
- Interference with Daily Life: Excess skin and fat from significant weight loss might interfere with your everyday activities, making it uncomfortable to move around or exercise.
- Muscle Separation (Diastasis Recti): Separated or weakened abdominal muscles can contribute to poor posture, leading to back pain and discomfort.
Relevant Medicare Item Numbers
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.
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 and is limited to once per lifetime.
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.
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.
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.
Steps to Claim Medicare Coverage for Abdominoplasty
If you believe you might qualify for Medicare coverage for your abdominoplasty, here’s a simple guide to help you navigate the process:
First, schedule a consultation with your general practitioner. During this visit, make sure to discuss all your symptoms and health issues related to your abdominal area, especially any skin problems or discomfort you’re experiencing. It’s important to obtain a referral that clearly details the medical necessity of the procedure. By thoroughly explaining your situation, your GP can document the clinical need in your referral, which is a crucial step in demonstrating why the surgery is necessary for your health.
Next, find a Specialist Plastic Surgeon, like Dr Turner who is experienced in performing abdominoplasty surgery. During your consultation, they will assess your condition to determine if you meet the criteria set out in the Medicare Benefits Schedule and help you understand whether your situation qualifies for coverage and what that entails.
If you have private health insurance, take the time to review your policy. Understand what coverage you have for reconstructive surgery and check if you’ve met any required waiting periods. This can help you avoid unexpected costs and ensure you’re fully prepared.
What Costs Does Medicare Cover?
If your abdominoplasty procedure meets the MBS criteria, Medicare may provide rebates for:
- Surgeon’s Fees: A portion of the surgeon’s fee (the majority of surgeons in Sydney charge fees above the Medicare scheduled fee).
- Anaesthetist’s Fees: Partial coverage of the anaesthetist’s charges.
- Hospital Costs: Coverage is generally limited to public hospitals. Private hospital costs may require private health insurance.
Private Health Insurance and Abdominoplasty
If you qualify for Medicare, you may also be eligible for rebates on the abdominoplasty surgery from your Private Health Insurance Provider. This only applies if your condition meets the criteria for Medicare Item Number. You will need to have the right level of coverage and have served the waiting period. It is always a good idea to check in directly with your own Private Health Fund, regarding your policy as they can differ drastically.
Why the big price range for Abdominoplasty Surgery in Sydney?
The cost of abdominoplasty surgery in Sydney can vary depending on several factors, including the surgeon’s fees, hospital fees, anaesthesia costs, and whether Medicare or private health insurance provides any coverage. On average, the total cost for abdominoplasty surgery in Sydney can range between $15,000 and $45,000.
Dr Turner’s fees:
Patients seeking a standard abdominoplasty
- Privately Insured – $22,000
- Uninsured – $32,000
A formal quote will be provided after your consultation with Dr Turner that gives a better estimate of costs involved in your planned rhinoplasty procedure.
Do we ‘No-Gap’ Abdominoplasty?
Dr Turner does NOT offer ‘no-gap’ body contouring procedures like abdominoplasty or body lift surgery. Private health funds simply do not compensate surgeons, anaesthetists and other medical professionals adequately. This is due to the gap payment which is often less than 30% of what the average surgeon is charging for plastic surgery in NSW, making it impossible to run a modern plastic surgery practice in Sydney.
Can I have an Abdominoplasty done in the Public System?
Short answer today is NO. There is limited capacity to patients having abdominoplasty surgery performed in NSW public hospitals, with a waiting list often spanning several years. You can check with the NSW Government Surgery Access Line on 1800 053 456 to see if there is a surgeon near you that may be able to put you on a waiting list.
Can I Use My Super Fund to Pay for Abdominoplasty Surgery?
Superannuation is accessible when there is a serious medical condition, and the patient has no other means to fund the surgery. Many patients have made successful claims to undergo abdominoplasty or body lift surgery for medical need.
The process is currently managed by the Australian Taxation Office and if they approve the release, your super fund will then consider the grounds and release the funds if appropriate under the rules of your fund.
Accessing your superannuation is a serious process given it will impact your retirement savings. For that reason, we encourage prospective patients to seek financial advice before going down this path.
Next Steps
If you’re considering abdominoplasty and believe you may qualify for Medicare assistance, we encourage you to consult with your GP and schedule a consultation with Dr Turner.
- Schedule a Consultation: Contact us at 1300 437758 or visit drturner.com.au to book your appointment.
- Prepare for Surgery: Follow any preoperative guidelines provided, such as avoiding certain medications and arranging for post-surgery care.
- Plan for Recovery: Set aside time for rest and healing and arrange for assistance during your initial recovery phase if needed.
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Consult with a qualified healthcare professional to determine the best treatment options for your individual needs
