This information outlines the eligibility criteria for Medicare for abdominoplasty (tummy tuck) under two different item numbers. Here are the key points for each criterion:
Medicare item number 30177 (effective since January 2016):
- Patients must have lost enough weight to drop 5 BMI points (approximately 15-20kg).
- The weight loss should be unrelated to pregnancy.
- The weight loss should have been maintained without fluctuations for at least six months.
- Excess skin and fat interfere with the patient’s activities of daily living.
- The patient must have suffered from intertrigo or another skin condition that failed three months of conventional or non-surgical treatment.
Medicare item number 30175 (available since July 1, 2022):
- Abdominal muscle separation (rectus diastasis) caused by pregnancy should be present.
- The gap between the abdominal muscles must be at least 3cm, as confirmed by diagnostic imaging.
- Documented symptoms of pain or discomfort at the site of rectus diastasis or related symptoms like low back pain or urinary symptoms.
- Non-surgical treatment options, such as physiotherapy, should have been attempted but failed.
- Patients must be at least 12 months post-partum at the time of surgery.
It is important to note that these criteria are specifically for Medicare coverage of abdominoplasty. It is recommended to discuss these criteria with your referring GP, who can provide further guidance and ensure that the necessary information is included in the referral letter.