on behalf of Customer
“What are my options? Health fund says there are no restrictions and they will cover the abdominoplasty if my Dr follows the approval process. Dr says they wont follow the approval form (Specialist Eligibility form) as I am not eligible (under the new restrictions). So without an item number is it possible for my Private Health to pay towards my hospital charges?”
Is there any valid Medicare imposed restrictions on my surgeon to not use the Specialist Eligibility Form?
Or is the Medicare restrictions (the 4 requirements for an abdominoplasty) only so that Medicare doesn’t pay any benefits to the surgeon and the surgeon cant claim against the item number.”
These are the conditions the patient needs to meet;
MBS items 30165, 30168, 30171 and 30177 now clearly state that all 3 of the following criteria need to be met in order to be eligible for the MBS item:
(a) there is 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 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
If they don’t meet these criteria, there is NO item number that can be applied, and an SEF from is irrelevant, their operation is deemed cosmetic.
I’m not sure if Medicare will recant this rule, but I’d think not. I am not really aware of other item numbers that can be used.
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