While many types of cosmetic procedures aren’t commonly covered under Medicare in Australia, abdominoplasty is slightly more complex when it comes to eligibility.

Whether the procedure costs can be covered or not will typically depend on the medical reasoning behind the surgery, the specific circumstances of the patient, and how well the surgery will meet Medicare’s relevant item number criteria.

Essentially, an abdominoplasty isn’t always performed for cosmetic purposes. Sometimes, it’s performed to address muscle separation, remove excess tissue following significant weight loss, or reduce skin irritation or infections that occur under excess abdominal skin. If there’s a genuine medical need and certain criteria are met, Medicare may cover a portion of the procedure’s costs.

Let’s go through what to know if you’re considering abdominoplasty and want to understand whether Medicare will help to cover some of your procedure costs.

When abdominoplasty might be considered medically necessary

An abdominoplasty can’t simply automatically be considered a medically necessary procedure just because there’s some level of physical discomfort involved. Essentially, Medicare requires that there’s a clear and well-documented medical reason behind the surgery.

For example, if someone has undergone massive weight loss, which is generally defined as losing at least 5 BMI points, and is left with a significant amount of excess abdominal skin that’s affecting their quality of life physically, they may be considered eligible.

In these situations, the excess skin may be contributing to hygiene issues, chronic skin infections, or mobility limitations. The goal of the surgery could be to remove the excess skin in a way that improves function, rather than purely to make changes to the appearance of the area. However, surgeons will also consider the aesthetics of the results.

As part of the criteria, there often needs to be evidence that non-surgical options have been attempted to address the concerns, and that the skin condition or related issues are persistent and have shown to be difficult to manage with other methods.

Another example of a reason that may be considered as medically necessary includes abdominal muscle separation (diastasis recti), which can occur after pregnancy and sometimes cause physical issues such as back pain, postural problems, or urinary incontinence. While this used to be a more difficult category to access Medicare cover for, a specific item number for postpartum abdominoplasty was reintroduced in 2022 under certain conditions.

The Medicare item numbers for abdominoplasty

For any surgery to be partially covered by Medicare, it needs to fall under a listed item number. These item numbers are very specific and they define what the procedure is, the conditions that must be met and what evidence is required.

For abdominoplasty, the relevant item number is usually 30177 or 30175, depending on the situation. These numbers relate to the removal of excess skin after significant weight loss and require documentation to support the extent of the weight loss, a minimum time period where the patient’s weight has been stable (usually six months), and evidence of functional issues caused by the excess tissue.

The newer item number 30175, introduced for postpartum cases, allows for cover when there’s diastasis of at least 3cm, documented pain or functional issues, and the patient has not responded to non-surgical treatment.

Your GP or specialist, as well as your plastic surgeon, can help to identify the item number that is relevant to you and outline the process that will be required.

Will private health insurance also help to cover costs?

Private health insurance can sometimes help to cover hospital costs associated with medically necessary abdominoplasty, but only if the procedure has a valid Medicare item number and your level of cover includes it.

The surgeon’s fee, anaesthetist’s fee, and other related costs may not be fully covered, and there’s usually an out-of-pocket cost involved even when insurance applies.

If you’re eligible for Medicare cover, you can then contact your private health insurance provider directly to find out if your level of cover will help with the costs of your abdominoplasty. There may also be other requirements and steps that will be part of the process, so it’s always a good idea to organise this as soon as possible.

How to find out if you’re eligible for Medicare cover

The best way to determine whether the reason for undergoing your abdominoplasty procedure would be eligible for Medicare cover is to have a consultation with a surgeon who regularly performs the procedure.

Your surgeon will be able to tell you whether your situation is likely to meet the current criteria and walk you through the next steps, including any documentation that may be required. It can also be helpful to speak with your GP beforehand, particularly if you’ve had ongoing physical symptoms that may be relevant.

During a consultation with your surgeon, your medical history, weight stability, physical symptoms, and goals will be assessed. This is also when your surgeon can help to determine if you’re likely to meet the Medicare item number criteria.

If it looks like you might be eligible, they’ll often ask for documentation from your GP to help support your case. If you’re also planning to go through private insurance, you’ll also need to provide the item number to your insurer to confirm what is and isn’t covered under your plan.

Dr Charles Cope: Specialist Plastic Surgeon in Sydney and North Shore

If you’d like to discuss your reasons for undergoing an abdominoplasty with an experienced surgeon and if you may be eligible for Medicare cover, we recommend scheduling a consultation with Specialist Plastic Surgeon Dr Cope.

You’ll be able to discuss the costs of your procedure in much more detail during your consultation, including the reasonings behind your costs, how much may be covered by Medicare and the out-of-pocket fees that you may need to prepare for.

Please get in touch with our team to arrange your consultation in Sydney or North Shore. You are also welcome to contact us if you have any questions before you book your consultation.