Can I claim my tummy tuck on Medicare?
Patients keep asking: Will Medicare pay for my tummy tuck? - There is significant research to suggest that it can significantly reduce women's health and post-pregnancy discomforts such as back pain, muscle separation (diastasis recti) and incontinencetummy tuck. So is it covered? The answer is MAYBE IF you meet the specific criteria and conditions below.
Dr Craig Rubinsteinis one of Australia's top plastic surgeons and has performed thousands of surgeriesAbdominoplastienwith and without muscle repair over the years.
URGENT UPDATE: The Australian government has reinstated a Medicare item number for a tummy tuck for some post-pregnancy patientsDiastasis recti (split abdominal muscles)if you are eligible and meet the new criteria. This new 30175Medicare item number– enters into force on July 1, 2022. Read the30175 Medicare Part Number Data Sheet.
If you qualify for Medicare Item Number 30175, you may also receive a grant from your health insurance company. There will still be a significant out of pocket gap as tummy tuck surgery IS NOT FREE.
Can Medicare Cover Your Surgery? Information is just a click away.
How do you qualify for Medicare reimbursement for tummy tuck surgery?
To qualify for Medicare reimbursement, you must meet certain Medicare criteria for a tummy tuck. Your eligibility may depend on your health assessment.
You can also contact your chosen health insurance company directly to get a subsidy for the surgery and to see if you are eligible.
These MBS codes may apply to tummy tuck
- 30172 Lipectomy - multiple skin removal wedges after weight loss (for tummy tuck)
- 31075 Radical abdominoplasty with correction of rectal diastasis after pregnancy
- 30177 Lipectomy, tummy tuck after weight loss (abdominoplasty)
- 30179 Circumferential lipectomy (belt lipectomy): To remove excess skin in the event of massive weight loss
Full description of the MBS item number
30172Lipectomy, wedge excision of excess skin and non-abdominal fat that is a direct result of significant weight loss, no service associated with a service equivalent to Article 30165, 30168, 30171, 30176, 30177, 30179, 45530 45565 applies when : (a) has intertrigo or other skin disease where there is a risk of loss of skin integrity and conventional (or non-surgical) treatment has failed over 3 months; and (b) excess skin and fat interfere with activities of daily living; and (c) weight was stable for at least 6 months after significant prelipectomy weight loss; and (d) the procedure involves 3 or more excisions (H) (anaes.) (assist.)
30175Radical abdominoplasty with repair of diastasis recti, excision of skin and subcutaneous tissue and umbilical repositioning, no laparoscopic intervention if the patient has an abdominal wall defect secondary to pregnancy if:
- have a diastasis of at least 3 cm as measured by diagnostic imaging prior to this service; And
- has symptoms of at least moderate intensity of pain or discomfort at the site of diastasis in the abdominal wall during functional use and/or back pain or urinary symptoms likely to be due to diastasis recti, documented by the treating physician in the patient's medical record The service; And
- has not responded to non-surgical conservative management, including physical therapy; And
- have not been pregnant in the last 12 months
The Service is not a Service associated with any Service to which Section 30165, 30651, 30655, 30168, 30171, 30172, 30176, 30177, 30179, 45530, 45564 or 45565 applies
Applicable once in a lifetime
30177Lipectomy, excision of skin and subcutaneous tissue associated with excess abdominal skin and fat that is a direct result of significant weight loss, associated with a radical tummy tuck (pitanguy type or similar), with or without repair of the musculoaponeurotic layer and transposition of the Navel, as it is not a service related to a service to which Article 30165, 30168, 30171, 30172, 30176, 30179, 45530, 45564 or 45565 applies if: (a) Intertrigo or any other skin condition present at risk of loss of skin integrity and failure of 3 months of conventional (or non-surgical) treatment; and (b) excess skin and fat interfere with activities of daily living; and (c) weight was stable for at least 6 months after significant prelipectomy weight loss
30179Circumferential lipectomy as an independent procedure for the correction of excess peripheral skin and excess fat that is a direct result of significant weight loss, with or without a radical tummy tuck (pitanguy type or similar), which is not a service associated with a Service for this item 30165, 30168, 30171, 30172, 30176, 30177, 45530, 45564 or 45565 applies when: (a) a circumferential excess of excess skin and excess fat is complicated by intertrigo or any other skin condition in which the Risk of loss of skin integrity and failure of 3 months of conventional (or non-surgical) treatment; and (b) peripheral excess skin and excess fat interfere with activities of daily living; and (c) weight has been stable for at least 6 months after significant prelipectomy weight loss (H).
Are you considering a tummy tuck? Information is just a click away.
Tummy Tuck Guide
How to research if Medicare and MBS cover your surgical procedure
- The MBS is a very comprehensive list that can befully downloaded.
- Alternatively, you can just use thesearch functionto find your procedure.
- Even if you don't have a valid Medicare code for your procedure, your health insurance company won't cover the procedure either.
What to Expect When Applying for a Medicare Tuck Reimbursement and Private Health Insurance Grant:
- There will be a lot of paperwork when you are eligible for a refund
- The criteria are very strict and you may not meet the eligibility criteria
- You still have out-of-pocket expenses
- Some health insurance companies cover some hospital expenses (not all), but there are no guarantees
- Every fund and protection plan is unique - call your fund, research others, and research the current situation.MBS Online Criteriafor Medicare eligibility
- You'll probably spend hours on the phone with your insurance company/private health insurance provider to estimate what they cover and what they don't so you can work out your budget and payment methods.
- Some patients later request early release from retirement
Tip: "Fully comprehensive" from a health insurance company rarely means "fully comprehensive" - there remains a gap!
Some expenses can be significant for personalized expert procedures from an experienced FRACS plastic surgeon. Publicly traded health care funds may be more interested in serving their investors than their patients. Therefore, choose your health insurance company carefully.
Persistent abdominal bulging and diastasis recti after pregnancy
You're not alone. Up to 2 out of 3 women, possibly almost all women, experience separated abdominal muscles and chronic abdominal bulging after pregnancy. Exercise and diet are a good place to start to get your body back in shape. But if the muscles in your abdomen are torn and remain separated 12 months into pregnancy, diastasis recti often requires surgical correction. It is unlikely to resolve further on its own.
This correction of the severed abdominal muscles can be performed as part of an abdominal repair/skin reduction known as an abdominoplasty (often withsuction-assisted liposuction).
Item number 30175 benefits a small subset of patients who: aDiastasis of at least 3 cm as measured by diagnostic imagingprior to this service with moderate intensity pain or discomfort at the site of abdominal wall diastasis during functional use and/or low back pain or urinary discomfort and who have not responded to non-surgical conservative management, including physical therapy.
Tummy Tuck (Abdominoplasty) Before and After Photos
Abdominoplastik-Operation(Abdominoplasty) is a procedure that can help restore the appearance of your stomach after pregnancy or significant weight loss. This includes improving sagging skin and abdominal "bags".
Abdominoplasty Medicare Code Confusion
Changes in Medicare reimbursement structures for plastic surgery with functional versus primarily cosmetic benefits remain confusing for patients. The main reason for the Medicare code confusion is that the answer can vary from patient to patient. Problems after pregnancy alone do not indicate that Medicare reimbursement is required; must meet the criteria. Subsequent weight loss, if it meets strict criteria, could result in a Medicare code for unnecessary skin reduction.
The criteria for patients who have lost weight are strict and include the patient's obesity compared to differences in weight change (changes in BMI) and skin conditions.
Patients should be aware that Medicare's coding system is currently under review and change. Read the ASAPS research showing functional benefits of post-pregnancy tummy tucks and their call for a change in governmenttummy tuckInsurance coverage to improve women's health after pregnancy.
Medicare reimbursement and health insurance eligibility
Medicare does NOT cover most cosmetic surgeries, but some corrective cosmetic surgeries can. For example, a tummy tuck after significant weight loss that meets strict criteria may be eligible for Medicare or health insurance coverage.breast reductionÖBreast lift after pregnancyif the patient meets Medicare's strict reimbursement criteria and has moderate to severe breast ptosis.
Health insurance policies are notoriously complex and involve numerous disclaimers, exclusions, and waiting periods. However, there have been changes in the industry to simplify the guidelines in major plans and help consumers choose their best health funds.
Some corrective plastic surgery procedures may be reimbursed by Medicare if they meet strict patient criteria and require a medically necessary procedure.
Your GP and board doctor can determine if your needs meet Medicare's strict plastic surgery reimbursement criteria.
For patients who are concerned about Medicare reimbursement or funding for surgeries, it can be helpful to determine their current eligibility for coverage and plan procedures ahead of sudden changes in Medicare or health insurance policies.
In select cases of surgical necessity, it may also be helpful to explore your Surgery Payment Superfund:
- Even Australian health insurance companies may not always cover the cost of your surgery.
- Most healthcare funds go public and are primarily focused on generating shareholder returns and higher profit margins, rather than patient reimbursement rates.
- Insurance companies even try to blame medical professionals for low reimbursements and high out-of-pocket expenses instead of their management teams.
- They insist that a surgeon or doctor who has spent more than 2-3 decades gaining experience and qualifications must agree to a low "no gap" rate.
- Many argue that this strategy of blaming the surgeon is an attempt to divert attention from the fact that health insurance managers are constantly cutting reimbursements and increasing exclusions from surgeries to improve their outcomes.
- This is likely to result in large bonuses for the manager and administrative staff of the health insurance fund, but can be detrimental to policyholders in some situations.
Some post-pregnancy medical concerns and conditions include:
- reduced core strength of the separated abdominal muscles
- Constipation or lower back pain caused by a severed rectus abdominis muscle
- loose skin on the abdomen and a bulge (or hernia) in the abdominal area that prevents movement or good posture
- Slight urinary incontinence due to abdominal muscle tears (rectus diastasis)
- superfluous taut excess skin hanging like an apron over the waistline
- sagging breasts that cause neck or back pain
- deflated breasts and sagging nipples (post-pregnancy breast lift surgery can be reimbursed by Medicare if strict criteria are met)
- Skin infections caused by sagging skin, such as rashes under the breasts or under the sagging skin apron after pregnancy
Tummy Tuck (Abdominoplasty) Before and After Photos
Abdominoplastik-Operation(Abdominoplasty) is a procedure that can help restore the appearance of your stomach after pregnancy or significant weight loss. This includes improving sagging skin and abdominal "bags".
Medical Necessity vs. Cosmetic Procedures and Medicare Reimbursements
A valid medical reason for surgery that could result in reimbursement for minor surgery from Medicare and/or a health insurance company may include things such as:
- Reconstructive facial surgery after an accident
- Rhinoplasty (nose corrective surgery/nose reshaping) to clear a blockage in the nasal passage when an injury to the nose or other structural abnormality of the nose is preventing breathing
- Plastic surgery after removal of skin cancer
- hand surgery
- Damaged abdominal areas after pregnancy or caesarean section (certain criteria apply)
- Breast reconstruction after a mastectomy or other breast cancer treatments
- Surgery after rapid weight loss:
- surgical excision and reduction of excess loose skin or excess tissue folds, including by abdominoplasty, girdle lipectomy, or similar procedures
- Eyelid lift, where the sagging skin of the upper eyelid impairs vision
- Occasionally, breast lift or reduction surgery may be eligible for minor Medicare reimbursements for patients who meet very specific criteria, including:
- severe ptosis of the breast
- recurring health problems related to the size, location, or condition of the skin in the breast area
- The best way to find out about your insurance coverage is to speak to a doctor
- Request a referral for a consultation with Dr. Rubinstein on
You can often schedule a no-obligation consultation appointment without a Medicare referral. However, for every potentialMedicare reimbursementsFor corrective surgery, a referral prior to your consultation is essential.
Disclaimer: This information is of a general nature. It is only intended to give you an overview of the Medicare system.
Submit an inquiry form today to begin your post-pregnancy corrective plastic surgery or call a patient care coordinator at1300 264 811.
Further reading and references:
- Benjamin, R.D.; Van de Water, ATM; Peiris, CL (March 2014). "Effects of exercise on diastasis rectus abdominis in the prenatal and postnatal period: a systematic review". Physiotherapy.100(1):1–8.doi:10.1016/j.fisio.2013.08.005.PMID24268942.
- Structure and function of the abdominal muscles in primigravidas during pregnancy and immediately after birth.
Pleasecontact the office of Dr. ruby stoneto book a consultation or to request more information about plastic surgery procedures.
About dr Craig Rubinstein
dr Craig Rubinstein FRACS is one of themMelbourne's top board-certified plastic surgeonfor breast and abdominal surgery.
He has been rated as one of the top 3 plastic surgeons in Melbourne and one of the top 5 plastic surgeons on the Best in Australia website.
dr Rubinstein offers women individual tummy tucks and all forms of aesthetic breast surgery.
He uses only the highest quality Motiva breast implants and is known for his long-lasting, natural-looking results.
BOOK A CONSULTATION TODAY1300264811
The next steps on your surgical path
Would you like more information about your procedure?
- download aGuide to Free Proceduresin your chosen practice.
- Visit thefrequently asked questionsand readpatient opinionsMore information about the planned procedure.
- For more information on prices and payment methods, visit ourOP paymentbook page.
- You can also speak to our Patient Care Team Monday through Friday from 9am to 5pm at1300264811
Regarding your first request
- The consultation fee of Dr. Ruby Stone is $300.
- A referral from your general practitioner or specialist is helpful, but not essential.
- You need a Medicare referral to receive Medicare or plastic surgery health insurance,
- contact thepatient care teamto Coco Ruby Plastic Surgery today to book your consultation.
What to bring to your consultation
- We invite you to bring a friend or family member to help you review the information and your options.
- Also, make lots of notes and carefully review the documents provided.
- Keep in mind that you may have to undress for a physical exam, so wear simple clothes.
*Disclaimer: Individual results may vary significantly from patient to patient. The information we provide is general. To learn more about what to expect from your preferred procedures, make an appointment with one of our specialist plastic surgeons for a full medical history and surgical consultation. Read more about the variability of surgical outcomes in ourDisclaimer page.
What makes a tummy tuck medically necessary? ›
So, when is a tummy tuck necessary? After significant weight loss or multiple pregnancies, your stomach muscles may not return to their original positions. Tummy tuck procedures tighten or repair weak muscles while removing excess skin and fat from the abdomen.Does Medicare pay for tummy tuck after weight loss? ›
Medicare will pay for abdominoplasty — also known as a tummy tuck — after weight loss surgery if it is deemed medically necessary because excess skin is causing rashes or infections.Will Medicare pay for my face lift or tummy tuck? ›
Medicare will not cover elective plastic or cosmetic surgery. Yet, medically necessary plastic surgery may receive coverage. Below, we review Medicare's guidelines for plastic surgery benefits. We review what Medicare covers, what is not, and how to find a physician to cover your services.What qualifies you for a Panniculectomy? ›
You may be a candidate for a panniculectomy if you: have recently lost a large amount of weight and have loose belly skin that you want to remove. are experiencing hygiene issues from excess skin hanging below the pubic region. keep getting ulcers, infections, and other related issues under the hanging skin.How do I get rid of my hanging belly? ›
To lose stomach overhang you have to burn fat cells in both the fat you can see directly under the skin and also the more dangerous fat that you can't see that surrounds your organs. Cardio such as swimming, aerobics, running or dancing will burn this excess fat store.What can I do instead of a tummy tuck? ›
- Liposuction. Liposuction is one of the most popular cosmetic surgical procedures. ...
- ThermiTight. ThermiTight is a reasonable tummy tuck alternative that utilizes a special Thermi device to apply heat energy to the abdominal region. ...
- CoolSculpting. ...
- EmSculpt. ...
- That you have had significant weight loss defined as 5 BMI points or more (unrelated to pregnancy). ...
- The level of excess skin is interfering with daily living,
- The use of non-surgical treatment for skin irritation caused by excess skin has failed to work,
Does Medicare pay for skin removal surgery? Medicare covers skin removal if you are suffering from excess skin following weight loss. Excess skin removal may not be the step of weight loss you expected, but insurance may help pay for the operation.How much does a tummy tuck cost? ›
The average cost of a tummy tuck is $6,154, according to a 2020 American Society of Plastic Surgeons (ASPS) report. But that amount doesn't include costs for things like anesthesia, the operating room, or medication. Once you add in those costs, the price tag can soar to $20,000 depending on your location.What cosmetic procedures are covered by Medicare? ›
Facial reconstructive surgery after an accident or trauma. Nose surgery to rectify an obstructed nasal passage (for Septoplasty) or correct deviated nose (Rhinoplasty) Surgery following massive weight loss (removal of saggy skin, arm lift, abdominoplasty etc)
What surgical procedures are covered by Medicare? ›
Does Medicare cover surgery? Yes. Medicare covers most medically necessary surgeries, and you can find a list of these on the Medicare Benefits Schedule (MBS). Since surgeries happen mainly in hospitals, Medicare will cover 100% of all costs related to the surgery if you have it done in a public hospital.Will insurance cover tummy tuck for back pain? ›
Tummy tuck surgery may also be useful in treating chronic back pain brought about by weight issues. Despite all of these benefits however, abdominoplasty is not covered by insurance.What is the difference between a tummy tuck and a Panniculectomy? ›
A tummy tuck tightens the abdominal muscles and removes excess fat, skin, and tissue, while a panniculectomy is performed to remove a pannus. The pannus is a large flap of skin which is distended over the abdomen, genitals, and thighs following significant weight loss or complications from childbirth.How many pounds of skin is removed in a Panniculectomy? ›
Results: Average abdominal skin resection was 16.1 pounds, ranging from 10.3 to 49 pounds. Hernia repair was necessary in 13 patients. Additional surgery performed at the time of panniculectomy included skin reduction surgery of the back (40 percent), chest (32 percent), inner thigh (28 percent), and arm (28 percent).Does a Panniculectomy include pubic area? ›
Panniculectomy is a surgery done to remove stretched out, excess fat and overhanging skin from your abdomen. This can occur after a person undergoes massive weight loss. The skin may hang down and cover your thighs and genitals.What is a hanging stomach called? ›
A pannus stomach or abdominal pannus is when excess skin and fat begin to hang down from the abdomen. It can occur following pregnancy or weight changes and can cause emotional distress. When skin and fat around the abdomen hang down, it can resemble an apron.What does FUPA look like? ›
A FUPA looks like an extra layer of skin and fat just above the pubis. Some people have a larger mons pubis because of genetics. FUPA can also develop after weight loss or weight gain.What causes stomach overhang? ›
Pregnancy, weight loss, and weight gain can cause you to have an excessive amount of fat, tissue, and skin hanging down from your abdomen. Called “apron belly” because it looks like you're wearing an apron around your waist, it can also be referred to as a pannus stomach.How many sizes do you drop with a tummy tuck? ›
Most women lose between 2 and 3 pants sizes after a tuck, but there are patients who lose even more. If you had a lot of loose skin before the procedure, for example, you could go down 4 more pants sizes.Can you remove stomach skin without a tummy tuck? ›
If you're not interested in surgery, skin tightening with BodyTite or Renuvion is a great alternative to achieve tummy tuck-like results. Radio Frequency Assisted Lipolysis (RFAL, among others the brands BodyTite and Renuvion) is a powerful and proven method to tighten and lift loose skin.
Who should not get a tummy tuck? ›
Obese or overweight. Body Mass Index (BMI) over 30. Any previous clotting issues or surgical complications. Currently taking any medications, anticoagulants, or supplements that might interfere.Can you claim liposuction on Medicare? ›
Liposuction is a form of cosmetic surgery to reshape the body by removing body fat. Liposuction should be performed by a specialist plastic surgeon. Medicare does not cover the cost of cosmetic liposuction.Can you claim weight loss surgery on Medicare? ›
The criteria for Medicare to cover weight loss surgery.
In order for Medicare to regard weight loss surgery as necessary you must meet the following criteria: A BMI (body mass index) of 35 or more. Documentation that you have been severely overweight/obese for 5 years or longer.
Panniculectomy is considered not medically necessary as an adjunct to other medically necessary procedures, including, but not limited to, hysterectomy, or incisional or ventral hernia repair unless the criteria above are met.What are the weight requirements for a tummy tuck? ›
While there are no standard weight requirements for a tummy tuck, there are some guidelines most cosmetic surgeons follow. If your BMI is not over 35 and you are within about 30% of your ideal weight and in overall good health, you should be a viable candidate for plus-size tummy tuck surgery.What is a 360 Panniculectomy? ›
Tummy Tuck 360 combines circumferential liposuction of the trunk (back, hips/flanks, abdomen) with a tummy tuck for a truly dramatic re-contouring and restoration of the entire mid-section.What state is the cheapest to get a tummy tuck? ›
The price you pay will depend on the complexity of your procedure, your plastic surgeon's experience level, their location, and a few other key factors. Average tummy tuck costs in U.S. states range from $17,579 in Hawaii to just $6,611 in Mississippi, while the average cost of a tummy tuck in California is $12,287.What is a 360 tummy tuck? ›
A tummy tuck 360 generally includes both tummy tuck (removal of excess skin and fat) along with liposuction of the flanks and back. Lipo 360 does not include the removal of excess skin from the front and only includes liposuction of the abdomen, hips, flanks, and back.How long do you need off work after a tummy tuck? ›
The tummy tuck, medically known as abdominoplasty, requires approximately two weeks off work for full recovery. Most people can work at a computer after about four to five days, but plastic surgeons usually recommend two weeks to avoid any unnecessary stress on the body.How do you check if a procedure is covered by Medicare? ›
Where can I learn more about what Medicare covers? Talk to your doctor or other health care provider about why you need the items or services and ask if they think Medicare will cover it. Visit Medicare.gov/coverage to see if your test, item, or service is covered • Check your “Medicare & You” handbook.
What is abdominal Panniculectomy? ›
Panniculectomy is a surgery done to remove stretched out, excess fat and overhanging skin from your abdomen. This can occur after a person undergoes massive weight loss. The skin may hang down and cover your thighs and genitals.Does Medicare pay for 100% on surgeries? ›
Medicare Part B covers outpatient surgery. Typically, you pay 20% of the Medicare-approved amount for your surgery, plus 20% of the cost for your doctor's services. The Part B deductible applies ($226 in 2023), and you pay all costs for items or services Medicare doesn't cover.Does Medicare require pre approval for surgery? ›
Does Medicare require prior authorization for surgery? No, Medicare does not require prior authorization for surgery. However, your doctor or other health care provider may need to get approval from Medicare before Medicare will pay for some types of surgeries.Can you claim breast augmentation on Medicare? ›
Medicare does NOT cover cosmetic procedures. Typically, Medicare will only cover plastic surgery procedures that relate to function or reconstruction. Rebates are subject to change. Photos taken during your medical consult are critical evidence when it comes to getting eligible Medicare rebates approved.Can a tummy tuck be considered a medical? ›
Abdominoplasty when done to remove excess skin or fat with or without tightening of the underlying muscles is considered cosmetic and not medically necessary. Repair of diastasis recti is considered cosmetic and not medically necessary.Can you get a tummy tuck if you have health issues? ›
Yes, it can be safe to have a tummy tuck if you are medically optimized. Your high blood pressure should be treated by your medical doctor and stable. Your pre diabetes should be addressed with proper diet and your A1C should be stable.Why do you need a BMI for a tummy tuck? ›
Patients who present with a BMI in the “obese” category of 30 or higher have a significantly higher risk for infection, poor healing, and other life-threatening complications after complex surgeries such as a tummy tuck.Do you have to be a certain weight to get a tummy tuck? ›
Expect to be at a stable weight before your tummy tuck
It is important that you be close to your desired weight for six to twelve months before undergoing a tummy tuck. Most surgeons will recommend patients be between 10-15 pounds from their goal weight.