Will Medicare cover a Breast Lift or Tummy Tuck after Pregnancy?

will-medicare-cover-breast-surgery-and-tummy-tuck-surgery-mummy-makeover

Will Medicare cover Breast Lift Surgery or Tummy Tuck after Pregnancy?

Medicare Rebates for Breast Surgery after Pregnancy or Breastfeeding; Medicare and Abdominoplasty after Weight Loss  (Medicare and Health Insurance).

MEDICARE CRITERIA and UPDATES to Medicare MBS Codes and rebate eligibility for Plastic Surgery is highly confusing to the majority of patients in relation to:

  • medically-warranted surgery that has a cosmetic benefit in addition to a functional health benefit 
  • combined Plastic Surgery procedures (multiple operations in one theatre session)

First published in January 2017; last updated in November 2018.

FAQs re Medicare rebates for Abdominoplasty, Breast Lift Surgery and Breast Reduction after pregnancy or weight loss (Bariatric Surgery)

+-Will Medicare cover Tummy Tuck Surgery or Breast Surgery after pregnancy?

  • NO – Abdominoplasty rebates are not currently part of the MBS
  • MAYBE – rebates for Breast Lift surgery MAY apply if ptosis is severe enough and strict conditions are met
  • MAYBE – possibly YES for a Breast Reduction if criteria and documentation are met
  • Rebates can only be requested AFTER Surgery has occurred, and may only be approved if criteria is met and medical need is validated. There is no guarantee.

+-What happened to Medicare rebates for Tummy Tuck Surgery after pregnancy?

  • The MBS item code for Abdominoplasty was removed a few years ago by the Government despite backlash from women’s health advocates and researchers
  • 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 an Abdominoplasty (Tummy Tuck) after pregnancy have medically-warranted health benefits? Why was the code removed?

  • Surgery costs increased for women and mothers after the Australian Government and insurance companies stopped covering the procedure despite serious lobbying from women’s health advocates, doctors and patients.
  • This occurred 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 change in November 2018?

+-MBS Medicare rebates - Breast Surgery or Tummy Tuck Surgery AFTER Weight Loss VS Pregnancy

  • There is a current MBS code for Tummy Tuck or Lipectomy skin reduction in the abdominal area AFTER significant weight loss but NOT for pregnancy-related weight changes.
  • A MASTOPEXY Item code (45558 for bilateral breast lift surgery after pregnancy) remains BUT MBS Item code 45557 was removed as of 1 November 2018.
  • Stricter criteria and further diagnostic support documentation applies to all remaining MBS codes for Plastic Surgery.

Many women who have children may also have been obese or lost weight through bariatric surgery.

+-Does Medicare cover a Breast Lift for ptotic breasts after pregnancy or breast feeding?

  • Yes your surgery MAY be covered for a breast lift (Mastopexy) IF the ptosis is severe enough and meets criteria.
  • Photographic evidence must be supplied.
  • Applicable Rebates are more difficult to qualify for as ptosis must be quite severe in degree; these can only be requested AFTER Surgery has occurred and there is no guarantee you’ll be approved for a rebate.

+-Breast Lift Surgery AFTER Pregnancy - Are hospital expenses fully covered?

  • No private health cover is available if you do NOT meet the MBS code criteria (Health Funds rely on you having an MBS item number)
  • 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 and expenses or coverage.

+-Is it difficult to prove breast ptosis meets MBS criteria for a post-pregnancy breast lift?

  • Extensive documentation, photographic evidence and medical testing is required to assess and prove eligibility criteria.
  • Some surgeries now require photographs of patient conditions NOT ONLY before surgery but DURING surgery as well.
  • Applicable Rebates are more difficult to qualify for as ptosis must be quite severe in degree; these can only be requested AFTER Surgery has occurred and there is no guarantee you’ll be approved for a rebate.
  • Read the Medicare MBS updates and recent changes to plastic surgery MBS item numbers and criteria as of 1 November 2018.

+-If weight loss was unrelated to pregnancy, does body contouring plastic surgery qualify for an MBS code?

Health Insurance Coverage – An overview of skin reduction surgery and body contouring after pregnancy or weight loss such as after Bariatric Surgery.

  • If you lost significant weight NOT related to post-pregnancy conditions, such as losing weight after bariatric surgery, your skin reduction procedure(s) may be covered – such as a Belt Lipectomy or Abdominoplasty or Arm Reduction.
  • Typically, any coverage or rebates ONLY apply if any of these surgeries are performed as completely separate procedures – versus combined procedures in a single session.

+-Multiple Procedure Rules and MBS rebates for combined surgeries in one operation theatre session

Not being able to combine surgeries is a patient frustration. it simply means:

  • you may need to STAGE – or SEQUENCE – your body contouring and liposuction or breast lifting and lipectomy surgeries
  • so that you’re only doing one operation at a time (except for bilateral arm reduction or bilateral breast lift surgery).

If your excess skin is solely related to pregnancy or to normal levels of post-baby weight-loss, it does not warrant an MBS code at this time.

  • But even for a breast lift, which does have an MBS code (recently changed), it depends on your skin condition and the age of your children.
  • Medicare code for a breast lift WAS 45557 (MBS code removed on 1 November 2018).
  • New MBS codes are 45556 – Unilateral Mastopexy for Breast Ptosis and 45558 = Bilateral Mastopexy for Breast Ptosis.
  • Criteria descriptions are excerpted below.
  • Effective 1 November 2018, criteria definitions, documentation requirements and degree of ptosis are being changed again.


Read more about Breast Lift / Mastopexy surgery here or download a Cosmetic Surgery or Plastic Surgery Guide.


+-Criteria for Tummy Tuck coverage by Medicare/MBS or Health Fund (Private Health Insurance) such as BUPA

But even though studies show significant health benefits for Abdominoplasty and diastasis recti repair for women after having babies, that particular item for skin reduction after pregnancy remains OFF the Medicare Benefits Schedule.

Read more about the research into benefits of Abdominoplasty to post-partum women.

 

+-Skin Plastic Surgery after Weight Loss: What's happened to Abdominoplasty, Belt Lipectomy and Liposuction Medicare codes on the 1st of November 2018?

+-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 after post-gastric sleeve surgery, lap band or gastric sleeve surgery for obesity, or other bariatric surgery procedures MAY be covered if strict criteria are met.
  • Photographic documentation and testing or imaging is required.

If you are contemplating Abdominoplasty and diastasis recti (torn abs) repair – or skin reduction after weight loss NOT RELATED to pregnancy, or to breast lift or tummy tuck surgery after pregnancy with or without significant weight loss, your coverage may depend on how much skin redundancy you have, and how much ptosis/weight changes are contributing to your health conditions.

Please phone our office a call on 0388491444 to find out more.

+-Is Breast Lift Surgery (Mastopexy) for breast ptosis after pregnancy or breastfeeding still COVERED by Medicare MBS item codes or Private Health Insurance such as BUPA? after 1 November 2018?

Or are you scheduled to have a breast lift for droopy nipples/sagging breasts after breastfeeding?

Are you worried about MBS codes changes that went into effect on 1 November 2018?

+-Breast Lift (Mastopexy Plastic surgery) Medicare Criteria - Basic Terminology

http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=45557&qt=item&criteria=Mastopexy

  • Medical terms for Breast Surgery
  • A Breast Lift is medically known as a Mastopexy.
  • The two key types are Mastopexy on its own, Breast Augmentation/Mastopexy (BAM), or a Mastopexy as part of a Breast Reduction Mammoplasty procedure.

+-MBS Rebates for Breast Lift Surgery: Medicare Criteria, MBS Item Codes and Descriptions under Therapeutic Procedures for ITEM #45558 - Bilateral Mastopexy

The MBS lists this Plastic Surgery procedure as a Category 3 – THERAPEUTIC PROCEDURES and it is MBS ITEM Code: 45558 (Bilateral) or 45556 (Unilateral).

MBS Code# 45557 was REMOVED from Medicare listings on 1 November 2018.

Group T8 – Surgical Operations
Subgroup 13 – Plastic And Reconstructive Surgery
Subheading  4 – Other Grafts And Miscellaneous Procedures

+-Breast Lift Rebates and Amounts: Rules, Definition and Criteria for MBS Code 45558 Mastopexy

Source: Excerpt accessed online on 5 November 2018:

Item 45558 – Bilateral Mastopexy for Breast Ptosis

Breast ptosis, correction by Mastopexy of (bilateral), if:

(a) at least two-thirds of the breast tissue, including the nipple, lies inferior to the infra-mammary fold where the nipple is located at the most dependent, inferior part of the breast contour; and

(b) if the patient has been pregnant—the correction is performed not less than 1 year, or more than 7 years, after completion of the most recent pregnancy of the patient; and

(c) 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.

Multiple Operation Rule – – meaning you cannot combine procedures

The primary reason for patient confusion about Medicare or Health Insurance Rebates is that the answer of FULLY COVERED varies from patient to patient and from operation to operation.

It also changes on a regular but unpredictable basis, as occurred again on 1 November 2018.

pregnancy-effects-on-breasts-and-breast-tissues

A post-pregnancy Abdominoplasty (Tummy Tuck) isn’t covered by Medicare or Health Funds; but after weight loss, it may be.

A breast lift after weight loss or pregnancy may also be covered so long as strict criteria and photographic documentation are met.

 

Phone us to discuss surgery or accepted payment options – (03) 8849 1444.

We also have helpful surgery planning guides.

Latest Changes to the MBS regarding Plastic Surgery

In a nutshell:

  • MBS codes are subject to unpredictable changes.
  • Cosmetic Surgery is NEVER covered by Medicare.
  • Some Surgery after pregnancy, however, is corrective in nature, such as breast lift procedures for moderately to severely ptotic nipples.

Your GP and Specialist may be able to ascertain if your requirements meet the strict Medicare rebate criteria for plastic surgery of the breasts or abdomen such as repair of diastasis recti.

Visit our Downloadable Guides pages

For more information about Cosmetic and Plastic Surgery options and research in Australia.

cosmetic surgery for women and men Downloadable guides Female Plastic Surgeon Melbourne

Download our free guides or phone (03) 8849 1444 today – and ask for a no-obligation consultation.

Recommended Video Viewing

Four Corners VIDEO link – the ABC Four Corners program team recently did an expose on Cosmetic Doctors and patients who didn’t know they were NOT Plastic Surgeons – click here to watch.

This blog is intended to give you a general overview of the Medicare system and plastic or cosmetic surgery procedures. It is not comprehensive and other updates may apply.

Be sure you join our e-newsletter list to be kept up to date on the latest changes to Plastic Surgery and news in the cosmetic or plastic surgery industry.

  • The Medicare Rebate Scheme (MBS) is subject to change
  • Health fund insurance companies also regularly change their policy coverage and surgery exclusion criteria to try to improve their bottom lines and increase their profit margins
  • You should always check the most up to date information via Medicare and your insurance company.
  • Contact us on (03) 8849 1444 to discuss estimated out of pocket expenses for your specific surgery or to request a new QUOTE if your MBS item number was impacted by changes to Medicare items for Plastic Surgery.
  • Our team can also give you information about our accepted payment methods, or if you have a medical reason for applying for early release of SUPER for your surgery, that may also be an option.

Send an enquiry form TODAY (below) to get started on your post-pregnancy makeover surgery procedures, or phone a Patient Care Coordinator on (03) 8849 1444.

We look forward to helping you get your body contours back after pregnancy or weight changes.

 


REFERENCES or additional reading for Medicare and Plastic Surgery updates:

https://ama.com.au/ausmed/tummy-tuck-can-ease-back-pain-incontinence-study

http://privatehealth.gov.au/healthinsurance/whatiscovered/medicare.htm

http://www.plasticsurgery.org.au

http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/downloads

https://chf.org.au/publications/what-mbs

https://plasticsurgery.org.au/wp-content/uploads/2018/08/Medicare-plastic-surgery-changes.pdf

 

 

 

Dr Craig Rubinstein - MBBS, FRACS (Plast)
Dr Craig Rubinstein MBBS, FRACS (Plast), a Specialist Plastic Surgeon, is one of Australia's most respected Melbourne Surgeons for Breast Augmentation, Breast Lift (Mastopexy), Breast Reduction surgery and Abdominoplasty procedures. Using advanced surgical techniques to gain better body contouring and natural-looking surgical results, Dr Rubinstein is highly regarded by peers and patients for best-practice Clinic Patient-care and patient education strategies. He published a chapter on corrective surgery for Breast Asymmetry (see: https://clinicalgate.com/breast-asymmetries/) Dr Rubinstein, a Melbourne University medical graduate and current FRACS Specialist Plastic Surgeon, is renowned for his skill and precision with breast enhancement procedures. With over 20 years experience in female cosmetic procedures, he has performed over 7,000 breast enhancement surgery procedures including breast augmentation, breast lift and breast reduction, and thousands of Abdominoplasty procedures for women after pregnancy or weight changes (post-obesity/post-bariatric surgery).Qualifications/Training Fellow of the Royal Australasian College of Surgeons (FRACS) The Australasian Society of Aesthetic Plastic Surgery (ASAPS) The Australian Society of Plastic Surgeons (ASPS) The Australian Medical Association (AMA) American Society of Plastic Surgeons (ASPS) The International Society of Aesthetic Plastic Surgeons (ISAPS)Founder: Cosmetic Surgery for Women and Men - Plastic Surgeons Group Bio Page: https://plasticsurgeons.com.au/dr-craig-rubinstein-plastic-surgeon/