Will you be able to receive Medicare rebate for your tummy tuck surgery, taking into consideration the recent Medicare Item Number changes? We get together with Plastic Surgeon Dr Gavin Sandercoe from Bella Vista in NSW to try to answer that question for you.
At the end of August we reported on the speculation that the funding for abdominoplasty would be revoked. A statement released from the Minister of Health on 28 December 2015 indeed confirmed that the Turnbull government is reviewing all 5,700 items on the Medicare Benefits Schedule and that includes many updates, new inclusions and old number cessations; including the tightening (excuse the pun) of patients’ access to rebates for tummy tucks.
Dr Sandercoe says, “A key step in modern abdominoplasty procedures is repair of rectus muscle separation. Specialist Plastic Surgeons have had anecdotal reports of functional improvements in lower back pain and stress incontinence for years. In 2015, a group of Australian Plastic Surgeons began gathering data on the functional improvements after tummy tuck surgery and have been able to prove substantial improvement in pain and social disability scores. This data was provided to the National Department of Health during discussions regarding the use of the abdominoplasty item number. It is very disappointing to know that Medicare and the Department of Health have turned their back on the functional improvements conferred to mothers by tummy tuck surgery.”
The Medicare Benefits Schedule now clearly states that a lipectomy (tummy tuck) surgery does not make available rebates when that surgery is for cosmetic purposes. However, you can still access the benefits when you are having it done for the management of significant weight loss.
Dr Sandercoe says “The new Medicare descriptions state the following criteria must be met for the use of item number 30177 (abdominoplasty or tummy tuck)
- Significant weight loss, defined as greater than 5 BMI units
- Weight stability for > 6 months
- There is intertrigo or evidence of skin irritation that has failed 3 months of conservative treatment
- Skin folds are interfering with activities of daily living
For those that are wondering, 5 BMI units translates as 10kg for 150cm tall, 12kg for 160cm tall, 14kg for 170cm tall, 16kg for 180cm tall.
There is an additional item number (30176) for abdominoplasty with muscle wall weakness after removal of intra-abdominal or pelvic tumors. Patients do not need to meet the above criteria, but do need to be approved through a Medicare photo review.
In essence, Medicare has redefined the standard abdominoplasty item number squarely aimed at post massive weight loss patients with over hanging skin folds with sweat irritation in the folds.
It will be very difficult for post-baby mothers to meet the above Medicare criteria. The Medicare criteria state ‘for significant weight loss that has occurred following pregnancy, the products of conception (i.e. baby & placenta) must not be included in the calculation of baseline weight’. In essence, this means that mothers could get their baseline weight measured by their GP as soon as they are feeling up to a visit. However, proving criteria 3 & 4 may be difficult for some mothers.
A useful link is to explanation T8.8 within the Medical Benefits Schedule.
So, what are the Medicare item numbers for tummy tuck/abdominoplasty surgery, or where can you find exactly what you are covered for?
We recently posted a list of Medicare item numbers, and the only change to this list is that item 30174 for Lipectomy – subumbilical excision, no longer exists. There are also amendments to item numbers 30165, 30168, 30171, and 30177. There is also an introduction of item number 30176 for circumferential lipectomy. Again, these numbers all specifically relate to significant weight loss with skin irritation and interruption of ability to live a normal daily life. If you would like to search and read about each of these item numbers in more detail you can do so by following this link… just type in the number above you wish to search for in the top right hand corner of the page where it says Search the MBS.
It can get confusing when you don’t know the medical terms and specific type of abdominoplasty surgery you are best suited for, however as always, we recommend you consult with a qualified Australian Specialist Plastic Surgeon, whether it be Dr Sandercoe, or any of the other excellent Australian surgeons we have listed on our website who will be able to talk you through your specific needs and requirements for tummy tuck/abdominoplasty surgery and whether or not you are eligible to receive a Medicare rebate.
Dr Sandercoe says, “As governments look to reign in health care costs without raising taxes, patients should expect things to get tougher to get Medicare (and therefore Private Health Insurance) assistance for any procedure that is not cancer or trauma related. It will not be long before photographic evidence will be required for any abdominoplasty, or breast procedure. Eventually the same processes will be applied to all procedures such as spinal & orthopaedic surgery.”
If you are considering Plastic or Cosmetic Surgery at any time now or in the future we suggest you take out Private Health Insurance and read the fine print to ensure you are at least partially covered for your procedure. A lot of Private Health Insurance companies are really strict and specific when it comes to what Plastic and Cosmetic surgery procedures they cover – read more about that here.
Dr Gavin Sandercoe advises “Medical billing is incredibly complex and changes between different hospitals and health funds. For instance, the hospital where I do most of my work has bands of codes – if you are having a major operation for which your Health fund covers you, then the cost of an additional cosmetic procedure is less than it would be if you were having the procedure alone, or in conjunction with a reimbursed procedure from a lower band. In addition, please be very aware of what you are getting yourself into with health funds and plastic surgery. The recent changes by Medibank Private, BUPA and NIB are aimed at increasing company profits through minimising the provision of Medicare endorsed surgery, and plastic & reconstructive surgery are the testing grounds”.
If you would like more information on Dr Gavin Sandercoe go here; or you can phone his office directly on 1300 112 358.