I had Tummy Tuck Surgery Jan 2012. I had Cigna Insurance & my surgeon is contacted w/ Cigna. Afterwards...the surgeon said mine was not a "medical case." - but didn't give me measurements of diastasis rectus. I recently got copy of my medical file (for taxes) . 17 months after surgery I found out I had a 10 cm diastasis rectus. Why do you think he didn't consider mine a "medical case" and have the office send in a claim. . Is there anything I can do now - to re-coupe cost from insurance?
10 Cm Diastasis Rectus - Would That Be Considered a Medical Case with Insurance?
Doctor Answers (15)
you clearly have the option to pursue cigna. they do not consider a diastasis recti to be medical y necessary and do not pay for the procedure
Tummy Tuck as Medical Case #tummytuck
Unfortunately it is not an insurance case. Hernia surgery can be an insurance case. What you describe is usually from women having children an the two rectus muscles are stretched so much that the attachments that usually hold them together have pulled apart. We commonly sew them back together when we perform tummy tuck surgery. Your surgeon does not sound like he/she did anything wrong. The distance of the diastasis does not make it a case that is covered or not. It is cosmetic.
Is rectus diastasis covered by insurance?
Under most insurance plans, rectus diastasis is not a covered procedure for medical necessity. Hernia is covered for hernia repair, but no aspect of the abdominoplasty is covered by insurance unless other criteria are met.
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Diastasis and Insurance
- In my experience, insurance companies never cover the repair of rectus diastasis.
- Therefore, unfortunately, I think trying to get your insurance company to pay retroactively is likely a waste of your time.
Tummy tuck is not covered by insurance (unfortunately)
Thanks for your question. Although 10cm is wide, it doesn't usually affect the function of your abdominal wall. Therefore the insurance company doesn't cover this type of surgery in my experience.
Diastasis Recti and Insurance Coverage?
At this point (given that the procedure has already been performed), I think that you will be wasting your time/efforts in pursuing insurance reimbursement. Chances are remote, if any, that an insurance company will consider correction of a diastasis recti ( no matter what the measurements) a medically necessary procedure.
What is considered covered by insurance?
When it doesn't affect your function or quality of life, it is usually considered cosmetic. A protruding tummy does not affect your function and diastasis is subsequently not covered as a benefit.
No Hernias, No Insurance by Villar
Diastasis recti is a midline separation between the rectus abdominis muscles. It is a common and normal condition in newborns. They usually grow out of it as the muscle grows.
Women typically develop it due to multiple pregnancies. Women 12 or more weeks pregnant should avoid aggressive abdominal exercises, which can worsen the condition.
Insurance typically does not cover diastasis recti unless it is associated with symptomatic ventral or umbilical hernias.
Medical Necessity & Rectus Diastasis
Thank you for your question. Unfortunately insurance companies have their own criteria for what consitutes medical necessity. In some situations it can be quiete arbitrary. Contact your insurance company and ask for the medical and documenation cirteria for rectus diastasis repair to be considered a medical necessity. Get copies of your records and the ICD 9 and CPT codes from your doctor and submit them to your insurance company. Insurance companies tend to be more responsive to their members. Best wishes.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.