Are Post Pregnancy Procedures Covered by Medicare in Sydney?
Medicare Australia, the country’s public health scheme, plays a significant part in ensuring Australians receive health care services they need. Designed to provide health care access to all Australians, Medicare covers various medical services and procedures. Medicare operates on the principle of universal access, providing free or subsidised treatment by health professionals such as doctors, specialists, and others. Also, Medicare provides free treatment and accommodation for public Medicare patients in a public hospital. From general consultations to specific medical procedures, Medicare is there to shoulder financial burdens associated with healthcare. In the context of post-pregnancy procedures, you need to understand what Medicare Australia covers. This understanding will help you plan your procedures better, considering your financial and health conditions.
Medicare – What Is Covered?
When it comes to understanding what Medicare covers, it’s vital to note that the coverage varies. Medicare primarily covers consultation fees for doctors, including specialists. It also covers tests and examinations needed for treating illnesses, like x-rays and pathology tests.
Medicare Australia also provides cover for surgical and therapeutic procedures performed by doctors. Some surgical procedures performed by approved dentists under specific conditions are also covered. Eye tests performed by optometrists are also part of the package.
For mothers it’s crucial to grasp what post-pregnancy procedures are covered by Medicare. A clear understanding of this will help you make informed decisions about your post-pregnancy treatment and procedures.
An Overview of Post-Pregnancy Procedures
Post-pregnancy, your body undergoes various changes. Some of these changes may require medical intervention. These procedures are designed to address any health concerns that have arisen as a result of pregnancy or childbirth.
One common procedure is abdominoplasty, commonly known as a tummy tuck. This procedure is often sought after by mothers who have had multiple pregnancies or those who have experienced significant weight loss. Another common post-pregnancy procedure is breast surgery. This could be a breast lift, reduction, or augmentation, depending on the individual’s needs and desires.
It’s crucial to remember that while these procedures can boost comfort, they are significant surgeries that require thoughtful consideration and understanding of the potential risks and benefits. It’s also essential to consider the financial aspect, which brings us to the role of Medicare.
Medicare Rebate for Abdominoplasty
Abdominoplasty, or a ‘tummy tuck,’ is a procedure that removes excess skin and fat from the abdomen, which often occurs after pregnancy or significant weight loss. This procedure can also restore weakened or separated muscles in the abdomen, creating an abdominal profile that is smoother and firmer.
Medicare Australia recognises the need for such procedures post-pregnancy and provides a rebate for abdominoplasty under specific conditions. The Medicare Benefits Schedule (MBS) lists the criteria that must be met for a patient to be eligible for the Medicare rebate for abdominoplasty. This includes a significant weight loss of at least 5 BMI points and the presence of persistent skin irritation despite optimal medical therapy.
Here are the Medicare Item Numbers for Abdominoplasty
Removal of redundant abdominal skin and lipectomy, as a wedge excision, for functional problems following significant weight loss equivalent to at least 5 body mass index points and if there has been a stable weight for a period of at least 6 months prior to surgery, other than a service associated with a service to which item 30175, 30176, 30177, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies (H)
Benefit: 75% = $616.10
Radical abdominoplasty, with repair of rectus diastasis, excision of skin and subcutaneous tissue, and transposition of umbilicus, not being a laparoscopic procedure, if:
(a) the patient has an abdominal wall defect as a consequence of pregnancy; and
(b) the patient:
(i) has a diastasis of at least 3cm measured by diagnostic imaging prior to this service; and
(ii) has either or both of the following:
(A) at least moderately severe pain or discomfort at the site of the diastasis in the abdominal wall during functional use and the pain or discomfort has been documented in the patient’s records by the practitioner providing the service;
(B) low back pain or urinary symptoms likely due to rectus diastasis and the pain or symptoms have been documented in the patient’s records by the practitioner providing the service; and
(iii) has failed to respond to non-surgical conservative treatment, that must have included physiotherapy; and
(iv) has not been pregnant in the last 12 months; and
(c) the service is not a service associated with a service to which item 30166, 30169, 30176, 30177, 30179, 30651, 30655, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies
Applicable once per lifetime (H)
Benefit: 75% = $796.90
Lipectomy, excision of skin and subcutaneous tissue associated with redundant abdominal skin and fat that is a direct consequence of significant weight loss, in conjunction with a radical abdominoplasty, with or without repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30166, 30175, 30176, 30179, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies, if:
(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
Benefit: 75% = $809.65
Circumferential lipectomy, as an independent procedure, to correct circumferential excess of redundant skin and fat that is a direct consequence of significant weight loss, with or without a radical abdominoplasty, not being a service associated with a service to which item 30175, 30176, 30177, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies, if:
(a) the circumferential excess of redundant skin and fat is complicated by 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 circumferential excess of 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
Benefit: 75% = $996.50
Lipectomy isn’t primarily used to treat obesity. Surgeries done solely for aesthetic reasons don’t qualify for MBS benefits.
To determine if a patient is eligible for lipectomy procedures (30166, 30177, and 30179) due to significant weight loss (SWL), they must have lost weight equivalent to a minimum of five BMI units. Additionally, their weight should remain consistent for at least six months after the SWL before undergoing lipectomy. Weight loss resulting from pregnancy shouldn’t factor in the baby’s weight and related elements when assessing initial weight for comparison.
Claims for the mentioned lipectomy procedures can’t be combined with items 45530, 45531, 45564, 45565, and 45567. If surgical closure of the abdomen and umbilicus reconstruction is needed after a free tissue transfer (45564, 45565, 45567) or breast reconstruction (45530, 45531), then the claim should be made under item 45571.
Medicare Cover for Breast Surgery
Breast surgery is another procedure often sought after pregnancy. Depending on your needs and goals, this could involve a breast lift (mastopexy), breast reduction, or breast augmentation. Each procedure has its own set of eligibility criteria to qualify for Medicare coverage.
Medicare Australia provides coverage for breast surgeries under certain conditions. For instance, breast reduction surgery is covered if it is deemed medically necessary due to physical symptoms such as neck pain, shoulder pain, or skin conditions. Mastopexy, on the other hand, is covered if it’s associated with a breast asymmetry condition.
Here are the Medicare Item Numbers for Breast Surgery
Reduction mammaplasty (bilateral) with surgical repositioning of the nipple:
(a) for patients with macromastia who are experiencing pain in the neck or shoulder region; and
(b) not with insertion of any prosthesis;
other than a service associated with a service to which item 31512, 31513 or 31514 applies (H)
Benefit: 75% = $1,109.55
Correction of bilateral breast ptosis by mastopexy, if:
(a) at least two‑thirds of the breast tissue, including the nipple, lies inferior to the inframammary fold where the nipple is located at the most dependent, inferior part of the breast contour; and
(b) photographic evidence (including anterior, left lateral and right lateral views), with a marker at the level of the inframammary fold, demonstrating the clinical need for this service, is documented in the patient notes
Applicable only once per lifetime, other than a service associated with a service to which item 31512, 31513 or 31514 applies
Benefit: 75% = $943.80
Breast ptosis, correction of (unilateral), in the context of breast cancer or developmental abnormality, if photographic evidence (including anterior, left lateral and right lateral views) and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes
Applicable only once per occasion on which the service is provided, other than a service associated with a service to which item 31512, 31513 or 31514 applies on the same side (H)
Benefit: 75% = $629.25
Breast Augmentation – only in case of asymmetry
Mammaplasty, augmentation (unilateral) in the context of:
(a) breast cancer; or
(b) developmental abnormality of the breast, if there is a difference in breast volume, as demonstrated by an appropriate volumetric measurement technique, of at least:
(i) 20% in normally shaped breasts; or
(ii) 10% in tubular breasts or in breasts with abnormally high inframammary folds.
Applicable only once per occasion on which the service is provided, other than a service associated with a service to which item 45006 or 45012 applies (H)
Benefit: 75% = $609.25
Is A GP Referral Required Prior to a Consultation with Dr Bish?
A GP referral is required if you are experiencing health issues that are eligible for Medicare or Health Fund coverage. It’s advisable to visit your GP and discuss post-pregnancy health concerns like back discomfort, sagging breasts, or urinary issues. This will enable you to obtain a referral for a Plastic Surgery evaluation. Without this referral, claims cannot be made, even if you qualify. Dr Bish always recommends patients secure a referral from their GP as a precaution.
Eligibility Criteria for Medicare Coverage
The eligibility criteria for Medicare coverage for post-pregnancy procedures are specific and strict. The procedures must be deemed medically necessary and not purely for cosmetic reasons. The specific criteria for each procedure are listed in the Medicare Benefits Schedule (MBS), which is publicly available.
To be eligible for Medicare coverage, you must meet these criteria and your doctor must confirm that the procedure is medically necessary. You should have a thorough discussion with your doctor about your symptoms and how they affect your daily life to ascertain if you meet the eligibility criteria.
How to Get Medicare Coverage for Your Surgery
- Medical Necessity: Medicare Australia typically covers procedures that are deemed medically necessary. For abdominoplasty to be covered, it would generally need to be deemed necessary for health reasons rather than purely cosmetic reasons
- Consultation with a Specialist: Before undergoing the surgery, you would need to consult with a specialist like Dr Bish Soliman who can assess your medical condition and determine if the surgery is medically necessary. The specialist would typically provide documentation or a recommendation indicating the medical need for the procedure
- Medicare Benefits Schedule (MBS) Item Number: If the procedure is deemed medically necessary, there might be a specific Medicare Benefits Schedule (MBS) item number associated with it. This item number is used to determine the level of Medicare rebate you might be eligible for
- Documentation: Ensure you have all the necessary documentation, including medical records, specialist recommendations, and any other relevant information that supports the medical necessity of the procedure
- Application Process: You might need to apply for Medicare coverage for the procedure, providing all the necessary documentation and information. It’s crucial to check with Medicare or a medical professional about the specific application process
- Out-of-Pocket Costs: Even if Medicare provides a rebate for the procedure, there will still be out-of-pocket costs. It’s essential to discuss these costs with Dr Bish’s team and understand what you might need to pay
- Private Health Insurance: If you have private health insurance, it’s also worth checking with your insurance provider to see if they offer any coverage or benefits for the procedure
FAQs about Medicare and Post Pregnancy Procedures
Does Medicare Australia cover post-pregnancy procedures like abdominoplasty, breast lift, and breast reduction?
- Medicare Australia may provide coverage for certain post-pregnancy procedures if they are deemed medically necessary. It’s essential to consult the Medicare Benefits Schedule (MBS) and speak with a medical professional to determine eligibility for specific procedures.
How can I determine if my post-pregnancy procedure is deemed medically necessary by Medicare?
- To ascertain if a procedure is medically necessary, you should consult with a specialist plastic surgeon like Dr Bish Soliman who can assess your condition. If the surgery is deemed essential for health reasons rather than purely cosmetic, it may be covered. Dr Bish will provide documentation or a recommendation indicating the medical need for the procedure.
Are there out-of-pocket costs associated with post-pregnancy procedures, even if they are covered by Medicare Australia?
- While Medicare may provide a rebate for certain procedures, there will still be out-of-pocket expenses. It’s essential to discuss potential costs with Dr Bish’s team and understand any additional fees you might need to cover.
Can I combine Medicare benefits with private health insurance for post-pregnancy procedures?
- If you have private health insurance, it’s worth checking with your insurance provider to see if they offer any additional coverage or benefits for post-pregnancy procedures. In some cases, combining Medicare benefits with private health insurance can help reduce out-of-pocket expenses.
Further Reading about Body and Breast Procedures with Dr Bish Soliman
- Read Dr Bish’s Body Contouring Surgery Page
- Read Dr Bish’s Tummy Tuck – Abdominoplasty Surgery Page
- Read Dr Bish’s Breast Augmentation Surgery Page
- Read Dr Bish’s Liposuction Surgery Page
- Read Dr Bish’s Breast Lift Surgery Page
- Read Dr Bish’s Blog about Abdominoplasty vs Liposuction or Combined Procedures