Does Insurance Cover Post-Pregnancy Body Contouring Surgery?

Posted: Tuesday August 15, 2023

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For many women, pregnancy changes the body in ways that diet and exercise alone cannot fully reverse. If you are looking for other ways to address these changes, you may be considering post-pregnancy body contouring surgery. But will your insurance cover the costs?

It is only natural to want to look into all of your options when it comes to an investment as significant as plastic surgery. Specialist plastic surgeon Dr Ellis Choy understands the sometimes overwhelming nature of deciphering insurance benefits. Together with his friendly and knowledgeable team, Dr Choy is committed to helping patients through the process of understanding their financing options for post-pregnancy body contouring surgery in Sydney.

What Is Post-Pregnancy Body Contouring Surgery?

Post-pregnancy body contouring surgery (formerly known as a mummy makeover) is a personalised suite of cosmetic procedures that aim to address the physical effects of pregnancy, childbirth and nursing. It is not a standard package but rather a customised plan designed to meet the individual needs of each patient.

The most common targets of post-pregnancy body contouring procedures are the breasts and abdomen. While these are not the only areas that can be addressed, they often undergo the most significant changes during the journey of motherhood.

Post-pregnancy body contouring surgery is typically performed as a single-stage operation combining two or more of the following procedures:

Depending on personal preferences and needs, additional procedures such as an arm lift, thigh lift or nipple/areola surgery might also be considered.

Is Post-Pregnancy Body Contouring Ever Covered By Insurance?

The question of insurance coverage for post-pregnancy body contouring is complex. While most aspects of the procedure are classified as cosmetic and elective, some may be eligible for insurance coverage under specific conditions.

Elective procedures are performed to enhance appearance or comfort, but they are not urgent or life-saving. Because of this classification, elective procedures are not covered by Medicare or private health insurance. In the context of post-pregnancy body contouring, many of the most popular procedures — like liposuction, breast lifting or breast augmentation — fall into this category.

Medically necessary procedures are recommended by a doctor to treat or diagnose a medical condition. If untreated, the condition could lead to worsened health or quality of life. These procedures are often covered wholly or partially by Medicare and private health insurers. For example, a breast reduction or abdominoplasty could be deemed medically necessary if the patient is experiencing health problems.

When Is Post-Pregnancy Surgery Covered By Insurance?

Insurance may cover elements of your post-pregnancy body contouring surgery if your referring physician says they are necessary for your health and well-being. The procedures most likely to meet the requirements are abdominoplasty and breast reduction.

Abdominoplasty

A tummy tuck may be viewed as medically necessary in specific instances, such as if you have an abdominal hernia or severe diastasis recti (separation of abdominal muscles) following childbirth. These conditions can cause:

Chronic back pain
Posture issues
Pelvic floor dysfunction

Breast Reduction

While often performed to improve body proportion, breast reduction can also relieve uncomfortable symptoms like:

Chronic neck and back pain
Shoulder indentations from bra straps
Skin irritations or rashes under the breasts

What Level of Coverage Is Necessary for Plastic Surgery in Australia?

Private insurers in Australia offer various tiers of coverage that can help pay for healthcare costs that Medicare doesn’t cover. What is covered and how much is covered depends on your policy.

All policies are placed into one of four tiers – Gold, Silver, Bronze or Basic — with Gold providing the most extensive coverage and Basic offering the most limited. Some insurers offer ‘Plus’ policies that include additional coverage beyond the minimum requirements of the tier.

Mid-level policies may offer some coverage for post-pregnancy procedures considered medically necessary. However, top-level policies are the most likely to include coverage for procedures like abdominoplasty and breast reduction. Before deciding on any surgical procedure, contact your insurance company to ensure you understand the level of coverage you have.

What Prerequisites and Documentation Are Required?

Regardless of your policy’s level, you will likely need:

A referral from a medical practitioner confirming the medical necessity of the procedure
Pre-approval from your insurance provider
Specific Medicare item numbers that correspond to the procedure(s) you’re having
Thorough documentation of symptoms or conditions that make the surgery medically advisable (often supported by diagnostic tests, photographs or other medical records)

What Are the Out-of-Pocket Expenses for Plastic Surgery?

Insurance typically covers some or all of your hospital fees. However, even with insurance coverage, undergoing plastic surgery in Australia often involves out-of-pocket expenses. These costs can vary widely depending on the extent of the surgery, the specific procedures involved and the level of your insurance coverage. Below is a general outline of the types of fees you might encounter:

Surgeon’s fee
Anaesthetist’s fee
Assistant’s fee
Post-surgery medication
Recovery garments and supplies

Although a small rebate may be available for these fees, it’s best to be prepared to pay them.

What Medicare Item Numbers Are Relevant?

You will only be eligible to receive benefits from your private health insurance provider if your circumstances meet the criteria for a Medicare item number.

Effective 1st of July 2022, the Australian Government reinstated a Medicare item number (30175) for a tummy tuck for postpartum patients suffering from diastasis recti. This new item number joined an earlier item number (30177) established for weight loss patients.

LEARN MORE: What Is the Cost of Tummy Tuck Surgery?

Several MBS codes may be applicable for breast reduction surgery in Australia, including 45520, 45522 and 45523. The full descriptions of all items can be found on the MBS Online website and discussed with Dr Choy.

LEARN MORE: What Is the Cost of Breast Reduction Surgery?

What Are the Next Steps?

If you are exploring your options for post-pregnancy body contouring and are curious about insurance coverage, the next step is to schedule a one-on-one consultation with Dr Ellis Choy. During this in-depth meeting, Dr Choy will assess your physical condition, discuss your aesthetic goals and provide personalised recommendations for your surgical plan.

Dr Choy and his team will assist you in navigating the complex landscape of Medicare and private health insurance coverage. They can help clarify which components of your post-pregnancy body contouring plan might be deemed medically necessary, and therefore potentially be eligible for insurance coverage, and what the likely out-of-pocket costs will be.

Should any of the procedures in your plan meet the criteria for medical necessity, Dr Choy will provide the necessary documentation to support your insurance claim.

Schedule a Post-Pregnancy Body Contouring Consultation With Dr Ellis Choy

Navigating the intricacies of aesthetic procedures and insurance coverage can be daunting. That’s why Dr Choy and his experienced team are committed to demystifying the process for you. With a focus on individualised care and financial transparency, we aim to make your post-pregnancy plastic surgery experience as straightforward as possible.

To schedule your consultation with Dr Ellis Choy, please call (02) 8962 9388 or submit an enquiry online.