A Guide to Medicare and Health Insurance for Breast and Tummy Surgery
Will Medicare Cover Breast and Tummy Surgery after Pregnancy?
Medicare rebates for Breast and Tummy Surgery after pregnancy
Medicare MBS Codes and rebate eligibility for Plastic Surgery can be subject to regular changes, and in turn, can be highly confusing to many patients.
Throughout this blog, we provide answers to some of our more frequently asked questions when it comes to Medicare rebates for Tummy and Breast surgery.
Will Medicare cover Tummy Tuck or Breast Surgery after pregnancy?
There is currently no MBS code for Tummy Tuck (Abdominoplasty) surgery.
However, rebates for Breast Lift surgery may apply if breast ptosis (drooping/sagging) is severe enough and strict conditions are met. Similarly, rebates may also apply for Breast Reduction surgery (subject to criteria and documentation approval).
Rebates can only be requested after surgery has occurred, and is subject to criteria with no guarantee of coverage.
What happened to Medicare rebates for Tummy Tuck Surgery after pregnancy?
- Despite backlash from women’s health advocates and researchers, the MBS item code for Abdominoplasty has been removed by the Government.
- MBS item codes still apply for Tummy Tuck surgery (Lipectomy) for weight loss not related to pregnancy.
- BMI changes must meet criteria and documentation and evidence apply.
Doesn’t a Tummy Tuck after pregnancy have medically-warranted health benefits? Why has the code been removed?
- Surgery costs increased for women after the Australian Government and insurance companies stopped covering this procedure.
- The MBS item code has been removed even though groups quoted peer-reviewed medical research indicating benefits of post-pregnancy Tummy Tuck surgery in reducing back pain, repairing abdominal area weakness, and reducing urinary incontinence.
What happened to MBS codes in November 2018?
- MBS codes for plastic surgery changed on 1 November 2018, with more stringent criteria and document requirements introduced.
- It may now be more difficult to qualify for rebates which can only be requested after Surgery has occurred.
- Additionally, there is no guarantee of approval for a rebate.
MBS Medicare rebates for Breast Surgery or Tummy Tuck Surgery after weight loss vs. after pregnancy
- There is a current MBS code for Tummy Tuck or Lipectomy skin reduction in the abdominal area after significant weight loss.
- However, there is not a code for pregnancy-related weight changes at this time.
- A Breast Lift item code (for Bilateral Breast Lift Surgery after pregnancy) remains, but MBS Item code 45557 has been removed as of 1 November 2018.
- Stricter criteria and further diagnostic support documentation apply to all remaining MBS codes for Plastic Surgery.
Many women who have children may also have been obese or lost weight through bariatric surgery. In this case, Medicare may cover the procedure, however, you must meet strict criteria including extensive documentation/photography.
Does Medicare cover a Breast Lift for ptotic breasts after pregnancy or breastfeeding?
Yes, your surgery may be covered for a Breast Lift (Mastopexy) if breast ptosis is severe enough and meets criteria. However, ptosis must be quite severe in degree and photographic evidence must be supplied.
Please note, you may only request a rebate after surgery has occurred and there is no guarantee of approval.
What is the MBS Item Code Number or rebate for a Mastopexy (Bilateral Breast Lift)?
- The MBS item number for a Bilateral Mastopexy for Breast Ptosis is 45558 (current as of Nov 2018).
- Click here to review the online MBS criteria definition for Breast Lift/Mastopexy surgery after pregnancy.
Are hospital expenses fully covered for Breast Lift surgery after pregnancy?
Private health cover will not be available if you do not meet the MBS code criteria. This is because Health Funds rely on you having an MBS item number for cover. Usually, there will be out of pocket expenses even if you have a good insurance fund.
Policies of Health Funds for plastic surgery hospital cover is changing to a tiered-system in 2019. This change may impact your surgery costs, expenses and/or coverage.
Is it difficult to prove that breast ptosis meets MBS criteria for a post-pregnancy Breast Lift?
- Extensive documentation, photographic evidence and medical testing will be required to assess and prove eligibility criteria.
- Some surgeries now require photographs of patient conditions both before and during surgery.
- Applicable rebates for Breast Lift Surgery are more difficult to qualify for as ptosis must be quite severe in degree. You can only request a rebate after surgery has occurred and there is no guarantee you will be approved.
If weight loss was unrelated to pregnancy, does body contouring plastic surgery qualify for an MBS code?
- Skin reduction procedure(s) may be eligible for an MBS rebate weight loss was as a result of lifestyle changes or bariatric surgery. Procedures may include Belt Lipectomy, Abdominoplasty or Arm Reduction surgery.
- Typically, any coverage or rebates only apply if these surgeries are performed as completely separate procedures, as opposed to combined procedures in a single session.
What are multiple procedure rules and MBS rebates for combined surgeries in one operation theatre session?
Not being able to combine surgeries is a common frustration among patients. To qualify for Medicare coverage, body contouring surgeries need to be staged, with only one operation performed at a time.
If your excess skin is solely related to pregnancy or to standard post-baby weight-loss, it does not warrant an MBS code at this time.
What happened to Abdominoplasty, Belt Lipectomy and Liposuction Medicare codes on the 1st of November 2018?
- Effective as of 1 November 2018, Plastic Surgery Medicare Code items and criteria definitions for many Plastic Surgery procedures changed again.
- This included some body contouring and liposuction procedures, as well as Breast Lift surgery for pregnancy-related ptosis.
What about Lipectomy or skin reduction in the abdominal area after bariatric surgery or significant loss of weight?
Lipectomy and skin reduction after weight loss or bariatric surgery may be covered if strict criteria are met. However, this is subject to photographic documentation and testing.
If you are contemplating Abdominoplasty or skin reduction after weight loss which is not related to pregnancy, your coverage may depend on how much skin redundancy you have, and how much these weight changes are contributing to your health conditions.
You can contact our Patient Care team on 1300 264 811 to find out more.
MBS rebates and item codes for Breast Lift Surgery: #45558 – Bilateral Mastopexy
The MBS lists Breast Lift Surgery as a Category 3 – therapeutic procedure and it is MBS item code: 45558 (Bilateral) or 45556 (Unilateral).
Medicare removed MBS Code# 45557 from listings on 1 November 2018.
- Group T8 – Surgical Operations
- Subgroup 13 – Plastic And Reconstructive Surgery
- Subheading 4 – Other Grafts And Miscellaneous Procedures
So, what should I keep in mind?
In a nutshell:
- MBS codes are subject to unpredictable changes. Private Health funds also regularly change their policy coverage.
- You should always check the most up-to-date information via Medicare and your insurance company.
- Medicare does not cover any Cosmetic Surgery.
- Some Surgery after pregnancy, however, is corrective in nature, such as Breast Lift procedures for moderately to severely ptotic nipples, and may be covered by Medicare. However, this is subject to strict criteria.
- Your GP and Specialist may be able to ascertain if your requirements meet the strict Medicare rebate criteria for Breast Lift Surgery post-pregnancy.
- Contact us on 1300 264 811 to discuss estimated out of pocket expenses for your specific surgery.
Download The Tummy Tuck or Breast Lift Surgery Guide or phone 1300 264 811 today and ask for a no-obligation consultation.
This blog provides a general overview of the Medicare system and plastic or cosmetic surgery procedures. It is not comprehensive and other updates may apply.