Will Medicare Cover My Mummy Makeover?

Will Medicare Cover My Mummy Makeover?

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Has pregnancy had an impact on your breast skin, nipple location and tummy tightness? Do you miss your pre-baby figure? For many mums, having a baby makes a radical difference to the skin and internal structures of the body. As a result, returning to your pre-baby body often involves more than eating well or rejoining Pilates. If you’re considering cosmetic surgery or plastic surgery to restore your post-baby body, you may consider asking “Will Medicare Cover my Mummy Makeover?”

Medicare was brought into place in Australia to provide a categorisation for medically necessary procedures where the costs are partially covered by the government. Medicare does not cover cosmetic procedures, only those deemed to be medically necessary. If your operation has an item number then your private insurance will also provide some money towards the costs of your procedure.

Unfortunately, this means if you hope to get breast implants for aesthetic reasons, it won’t attract a Medicare rebate or Private Health Insurance cover. But, if your saggy breasts are causing you distress or discomfort, you may be eligible for some sort of return.

How Much Does Medicare Contribute?

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This topic can often be confusing for patients, with many thinking their entire procedure can be subsidised. This simply isn’t true.

The Medicare Benefits Schedule outlines a set fee for certain procedures. Medicare will then only rebate 75% of the fees outlined in the MBS. These fees are significantly lower than the costs of the procedure itself.

And while the Medicare rebate may seem small in comparison to the cost of your Mommy Makeover procedure, there are some benefits. If you qualify for a Medicare item code, your Private Health Insurance is required to assist with the cost of medical services that fall under the MBS guidelines.

So, if you attract a Medicare code for breast or tummy surgery, you may be covered for private patient hospital cover, general cover (commonly known as extras), or combined hospital and general cover. This typically requires a comprehensive or “top cover” policy. It’s worth checking your policy if you hope to reduce your total out of pocket costs for Mummy Makeover surgery.

New Responsibilities for Plastic Surgery Patients

Another area of confusion is that Medicare will pay this rebate upfront – this is also untrue. It is now necessary for you to provide full payment for your surgery upfront.

Only when your surgery is complete, you can apply for the relevant Medicare and Health Fund rebates. You will, however, be advised by Dr Doyle whether or not you qualify for the rebates prior to your surgery taking place.

Will Medicare Cover My Mummy Makeover?

Now that the technicality of Medicare has been specified, we’ll take a look at the times Medicare may cover your mommy makeover procedure.

Pregnancy and breastfeeding alter most women’s breast skin and abdominal areas. But it’s important to understand that every patient is unique, so each Mum’s need for surgery can vary significantly.

Mummy Makeover surgery always consists of plastic surgery to your breasts (breast surgery) and also to your abdominal area (tummy tuck). This option is appealing to Mum’s who hope to regain their pre-baby bodies. And while you may not look exactly as you once did, you can certainly get your body looking closer to how it was before you had children.

This combination surgery is highly individualised and is always adapted to suit your requirements and aesthetic goals for surgery. You may choose to have the procedures combined, or in separate surgeries. Breast and tummy surgery procedures are more commonly performed together as it achieves a more dramatic transformation and reduces the expenses paid for hospital and anaesthetic fees.

What Surgeries Does a Mummy Makeover Include?

mommy makeover surgery
Image sourced from: estexcellent.com

Mummy makeover may include one or more of the following breast surgeries:

And one of the following tummy surgery options, with optional liposuction:

  • Mini tummy tuck
  • Tummy tuck
  • Extended tummy tuck

Many of these are considered cosmetic in nature, and only a select few will attract a Medicare rebate (given you can meet the criteria).

Will Medicare Cover My Mummy Makeover Breast Surgery?

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Having a baby is known to stretch the breast skin, resulting in loose, saggy skin after pregnancy. This is why breast surgery is one of the key components of a Mummy Makeover.

There are a few Medicare codes for breast surgery procedures that are available within a Mummy Makeover combination surgery. These include:

  • Bilateral Breast Reduction Item no. 45523
  • Breast Lift (ptosis) after pregnancy – Your youngest child must be between the age of 1 year and 7 years old and your nipples very low Item no. 45558
  • Breast Augmentation for Asymmetry Item no. 45560
  • Removal and Replacement of Breast Implant Item no. 45553, 45554

The criteria for these codes are as follows:

Item Number 45523 – Bilateral Breast Reduction

Reduction mammaplasty (bilateral) with surgical repositioning of the nipple:

(a) for patients with macromastia and experiencing pain in the neck or shoulder region; and

(b) not with insertion of any prosthesis

Note: Macromastia defines the condition where your breast size is disproportionately large in comparison with your other body dimensions. It causes physical issues that include neck and shoulder pain, as well as reduced quality of life.

If pregnancy caused your breasts to grow to a size that is too large for your body, and you’re suffering because of it, you may be eligible for this rebate (given you do not get breast implants).

To find out more, read our blog, Will Medicare Cover my Breast Reduction?

Item Number 45558 – Breast Lift (Ptosis) After Pregnancy 

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.

This Medicare code is applicable only once per lifetime.

Note: Dr Doyle states that it’s quite rare to have a nipple that is photographically at the lowest point of the breast so the use of an item number for ptosis is very low. For breast reductions, it’s more common. If you require a reduction in breast size, then a breast reduction (which includes a lift) can be done using Medicare item numbers.

To find out more, read our blog, Will Medicare Cover my Breast Lift?

Item number 45060 – Breast Augmentation for Asymmetry

Developmental breast abnormality, single-stage correction of, if:

(a) the correction involves either:

(i) bilateral mastopexy for symmetrical tubular breasts; or

(ii) surgery on both breasts with a combination of insertion of one or more implants (which must have at least a 10% volume difference), mastopexy or reduction mammaplasty, if there is a difference in breast volume, as demonstrated by an appropriate volumetric measurement technique, of at least 20% in normally shaped breasts, or 10% in tubular breasts or in breasts with abnormally high inframammary folds; and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

This Medicare code is applicable only once per occasion on which the service is provided.

Item Number 45553 – Removal and Replacement of Breast Implants

Breast prosthesis, removal of and replacement with another prosthesis, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture), if:

(a) either:

(i) it is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity; or

(ii) the original implant was inserted in the context of breast cancer or developmental abnormality; and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

To find out more, read our blog, Will Medicare Cover my Breast Implant Removal?

Will Medicare Cover My Mummy Makeover Tummy Surgery?

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Abdominoplasty, also known as a tummy tuck, is the go-to surgery for Mums struggling to rid themselves of body fat and excess skin after pregnancy.

Typically pregnancy damages the surface of the skin which can cause stretch marks. It can also loosen or spilt the abdominal muscles to accommodate the size of the growing fetus. This means you’ll have a belly bulge that is simply not fixable by exercise and diet alone, as your underlying ab muscles are ‘split’ or ‘broken’. You can find out more about this condition in our blog, How to Know if Your Abdominal Muscles Were Torn During Pregnancy.

Unfortunately, the Medicare coverage available for tummy tuck surgery applies mainly to those who’ve lost a significant amount of weight. A significant amount is defined as losing at least 5 BMI points. This equates to around 10 to 15 kgs of weight. For Mums, this weight loss is measured before you fall pregnant and does not include weight directly correlated to your pregnancy.

While there have been changes to the accessible rebates in the past, some surgeries to correct damage related to pregnancy may possibly be eligible for rebate support. This includes:

Item Number 30177 – Radical Abdominoplasty (Extended Tummy Tuck)

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 (Pitanguy type or similar), with or without repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30176, 30179, 45530, 45564 or 45565 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

It is important to note that these numbers are subject to change and you should speak to your doctor in-depth and research the MBS online criteria to make sure that the numbers have not changed.

To find out more about Medicare and tummy tuck surgery, read our blog, Will Medicare Cover my Abdominoplasty Tummy Tuck in Queensland?

What Are Medicare’s Rules Regarding Combined Surgery Procedures?

Medicare’s rules around combination procedures can be frustrating for Mums as post-pregnancy surgery typically requires more than one surgical procedure. Combined surgeries are typically required because Mums experience changes to multiple areas of their body after having babies. The areas most affected with pregnancy are the breasts and nipples as well as the abdomen.

Typically, Medicare and Health Fund rebate eligibility applies for single surgery sessions only. This means that rebates from Medicare (and Private Health Fund cover) will often not apply if you want to combine your breast surgery and tummy tuck surgery into one procedure.

It’s best to ask your GP or surgeon for details about your post-pregnancy conditions and if they meet the Medicare criteria. Then you can proceed in deciding if you would like to do the surgery as a single-stage procedure (with limited access to Medicare coverage) or as a two-stage procedure.

Will Medicare Cover My Mummy Makeover – Frequently Asked Questions

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Can diastasis recti be corrected as a part of a Mummy Makeover?

Diastasis recti is a common condition that involves the separation of the abdominal muscles. It is common after childbirth.

Abdominoplasty surgery, performed by a specialist plastic surgeon, has the power to restore separated muscles and also alleviate any hygiene issues caused by loose excess skin. The cosmetic goal of this surgery is to create a firmer and smoother profile of the tummy area.

Do I need a GP referral before my Mummy Makeover consultation?

Yes, if you have any conditions that qualify for Medicare or Private Health Fund insurance. The best thing to do is to see your GP with your post-pregnancy health complaints, such as back pain, breast drooping or urinary incontinence and to get a referral for a Plastic Surgery consultation.  Without a referral, a claim cannot be made even if you are eligible.  We encourage all patients to get a GP referral just in case.

When will Medicare cover my Mummy Makeover breast surgery?

Procedures that cause functional limitations such as excessively large breasts typically attract a Medicare item number.

Operations that involve breast implants are rarely covered by Medicare. If the procedure addresses a functional limitation, such as significant breast asymmetry, then this will be covered by a Medicare item number.

In relation to a Mummy Makeover, Medicare item numbers can sometimes be applied to these procedures if certain criteria are met. These procedures would include breast reduction, breast implant replacement, correction of congenital breast disease and of course, breast reconstruction after cancer treatment.

Will Medicare cover my Mummy Makeover abdominal surgery?

Medicare item numbers do apply if there has been a significant weight loss that has resulted in excess skin that creates functional problems, such as skin chafing.

If there has been a significant drop in the BMI (as discussed above) that has created laxity of skin, then Medicare item numbers could potentially apply.

What is the difference between a full tummy tuck and a mini tummy tuck?

Generally, a standard tummy tuck involves the reconstruction of the abdominal wall by rejoining the stomach muscles, removing any hernias and then reducing excess skin. The umbilicus is released from the abdominal skin with a circumferential incision made around it, to allow the upper abdominal skin to be pulled tighter. The umbilicus is then replaced in its original position.

Functionally this improves core strength, and aesthetically it provides a flatter, more sculpted abdomen. A mini tummy tuck only involves the removal of a small pocket of excess skin on the lower abdomen and is appropriate for women who do not have muscle separation, hernias or loose skin around their umbilicus.

Both of these procedures are deemed cosmetic in nature – meaning a Medicare rebate is unlikely to apply. For an extended tummy tuck, you may be able to claim item number 30177.

Is Mummy Makeover worth it?

The only person that can answer this question is the Mum who chooses to undergo this procedure. It is a very popular procedure with good outcomes.

Carrying children can leave a woman’s body with excess skin, separation of their abdominal muscles, and sagging breasts. For most of the patients that consult for Mummy Makeover, the procedure is less of an issue of vanity, and more of an issue of self-esteem and the desire to regain their pre-pregnancy body again.

Book a Consultation

If you would like to learn more about Mummy Makeover, or if you believe you qualify for a Medicare criteria, book a consultation with Specialist Plastic Surgeon, Dr Mark Doyle.

Related Blogs – Breast Surgery

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About Dr Mark Doyle FRACS (Plast) – Queensland Plastic Surgeon

Servicing patients in Gold Coast, Brisbane, Sunshine Coast, Cairns and New South Wales NSW – Northern Rivers, Byron Bay, Ballina, Lismore and more.

Dr Mark Doyle is a Specialist Plastic Surgeon with over thirty years of experience performing BreastBodyFace and Nose surgery. As a highly esteemed plastic surgeon, Dr Mark is driven by an intense passion for helping patients achieve a happier, more beautiful self through advanced cosmetic surgery procedures.

He maintains a strong commitment to achieving the best possible results for all his breast, body, face and nose patients, both men and women.