What do the recent announcements around the surgical repair of rectus diastasis in post-partum women(‘abdominoplasty’) mean?
Surgery to sew the abdominal muscles back together after pregnancy used to be covered by Medicare but was removed from the Medicare Benefits Schedule (MBS) in 2016 after concerns it was being misused for cosmetic purposes.
However, the Australian Government has recently reinstated the Medicare benefit for Abdominoplasty – Tummy Tuck item number for some eligible post-pregnancy patients if you meet the new criteria. This new item number to repair diastasis recti (Split stomach muscles) will be effective 1st July 2022.
What are the eligibility criteria in order to receive the Medicare subsidy?
The current PROPOSED descriptor includes the following criteria:
- Cause: The rectus diastasis (tummy muscle split) was caused by pregnancy
- Timing: The patient must be at least 12 months post-partum at the time of receiving the surgery
- Gap measurement: The gap between abdominal muscles must be at least 3cm as evidenced by a scan such as an ultrasound
- Symptoms: The patient must have documented symptoms of pain or discomfort at the site and/or low back pain or urinary symptoms
- Other treatment failed: The patient must have tried and failed to respond to non- surgical treatment options such as physiotherapy. Other examples of non-surgical treatment may be: symptomatic management with pain medication, lower back braces, lifestyle changes, physiotherapy and/or exercise.
(Please note that these criteria are subject to change prior to the benefit being launched on 1st July, 2022.)
Who decides if I’m eligible?
Your Specialist Plastic Surgeon will be able to assess your eligibility for this item number based on the criteria outlined by Medicare. However, there is an expectation that the following medical practitioners would have also been consultedprior to assist with the determination of eligibility.
- GP would have been seen for non-surgical management and treatment options. GPs would also need to make the referral to the Specialist Plastic Surgeon who will perform the surgery.
- Physiotherapist or other Allied Health practitioner such as an Exercise Physiologist may be seen if the patient tried physiotherapy or exercise programs
- Radiologist must have conducted an ultrasound to measure and confirm the inter rectus diameter (the size of the gap between abdominal muscles)
Private Hospitals & Medicare explained:
Private Hospitals work with both Medicare and Private Health Insurance (PHI) companies, so if you are eligible for the procedure, have Private Health Insurance, and have the procedure in a private hospital, Medicare and your Insurer may contribute to the total fees on your behalf, leaving you with a smaller gap fee or out-of-pocket expense. So, after Medicare pay the hospital and your Insurance pays the hospital, you may only need to pay a small fee. But this depends on the factors listed above.
What if I just don’t like the look of my tummy after pregnancy?
Medicare does not cover cosmetic procedures. A ‘tummy tuck’ is considered cosmetic. Those women seeking to improve the aesthetic appearance of their bodies without a functional impairment will not be eligible for the procedure and will have to pay the full cost of this procedure with no subsidy by Medicare or private health insurers.
Medicare will be conducting a review of usage of this procedure 2 years after it is implemented. If there is concern it is being misused for cosmetic purposes, we risk it being removed once again from the MBS to the detriment of those women who genuinely need this procedure for functional reasons.
What can I do to prepare for this surgery whilst awaiting its availability?
There are a few things you can do to start preparing for it, if you think you may be eligible.
- See your GP to discuss non-surgical treatment options or management of symptoms. These may include, but are not limited to: physiotherapy and/or exercise, symptomatic management with pain medication, lifestyle changes, lower back braces, etc. Bear in mind it will most likely be a requirement that you have tried to treat your rectus diastasis with non-surgical options before considering surgery. Your GP may refer you to a physiotherapist or other health professional to try non-surgical treatment options.
- Schedule diagnostic imaging for an ultrasound scan, which will provide evidence you have a diastasis (muscle gap) of at least 3cm as measured by the diagnostician.
- Look into your Private Health Insurance options so any wait times for claiming certain procedures can be ticking over whilst awaiting this procedure to become available. See the above question – What does being covered by Medicare mean to me & what are the likely costs? For some information that might help you decide.
Where can I find authoritative information?
ASPS will be updating information as they receive it from the Department of Health on their webpage dedicated to this announcement and procedure. We suggest you use ASPS information as we will be updated directly by the Department of Health who are responsible for overseeing MSAC’s support through to implementation onto Medicare. You can find that information HERE: