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Insurance Coverage for Muscle Repair from C-sections Damage?

I have had four C-sections and have a few areas in my muscle wall that need to be repaired, beyond cosmetic issues. I am only about 10 pounds over my ideal weight but most of it is in my tummy. Will insurance cover any of the expense due to muscle damage?

Doctor Answers (12)

INSURANCE COVERAGE FOR A TUMMY TUCK

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In my practice this is a very common question as it would seem likely that restoring the body after pregnancy would be medically necessary especially since pregnancy can cause diastasis of the abdominal muscles.  A diastasis is a slight separation of muscle that can cause abdominal laxity which can be furthered strained after c-section procedures leaving some women with a “pouch” in the lower abdomen.  The only way to improve the diastasis and tighten the abdominal muscles is with an abdominoplasty.  Unfortunately, insurance companies do not cover abdominoplasty procedures because they do not consider repairing a diastasis as a reconstructive procedure regardless of what the cause of the muscle separation may be.  To be considered a reconstructive procedure, a procedure needs to restore functionality, correct a deformity, or repair a defect like a hernia.  A hernia involves a complete separation of muscle that allows the internal organs to protrude into the abdomen.  For patients who have a history of multiple failed hernia repairs, abdominal wall reconstruction can be done to close the defect and reinforce the abdominal muscles.  However, abdominal wall reconstruction does not tighten all of the abdominal muscles or remove large amounts of excess tissue like a tummy tuck.  Typically after pregnancy, women require a tummy tuck to restore their pre-pregnancy bodies but without a physical examination it is difficult to provide an opinion as to which procedure is best for you.  I recommend scheduling a consultation with a board certified plastic surgeon to receive a customized surgical plan to help you achieve your pre-pregnancy look.

Be well and good luck!

@norrisplastic


Houston Plastic Surgeon
4.5 out of 5 stars 18 reviews

Insurance coverage for muscle repair from c-sections damage?

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Hello! Thank you for your question! Surgical procedures for aesthetic purposes, to improve appearance, are not covered by insurance. Typically, these as well as complications resulting from such procedures are the responsibility of the patient. Procedures that are meant to correct functional issues and those which cause health-related issues should be covered by your insurance as a medical necessity, with proper examination and documentation. Some insurance plans have exclusion criteria for certain procedures. Also, it is an obligation of the surgeon not to attempt to authorize purely cosmetic procedures through insurance.

Discuss your issues and complaints with a board-certified plastic surgeon to discuss these as well as to examine and assist you in deciding which procedure(s) will be the best for you. A discussion of the advantages and disadvantages will take place along with the risks and benefits. Insurance companies will vary on coverage and is always reasonable to discuss your issues with your surgeon and primary care. It would behoove you to get as much information as possible and even call your insurance yourself. Certainly, pay in advance prior to your surgical procedure and options such as financing are available if you qualify. Hope that this helps! Best wishes!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 12 reviews

Abdominal Wall Hernia

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If you have an abdominal wall hernia, then insurance will cover this.  But what they wont cover is thightening of the abdominal wall and excision of the skin, i.e. abdominoplasty.  You need to see a general surgeon to see if you have a hernia that needs to be fixed.

Good luck.

Farbod Esmailian, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 46 reviews

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Hernia or not

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Insurance companies will provide coverage for repair of an abdominal wall hernia if one exists. More commonly, however, there is not hernia but a weakness in the abdominal wall called a rectus diastasis. While this may be distressing it posed not health concerns and is therefore not a deformity typically covered by you health insurance provider. As for performing a tummy tuck when an abdominal wall hernia is repaired, this is certainly feasible and often convenient. Its repair, however, does not require that a tummy tuck be performed so don't expect that they will authorize coverage of the tummy tuck. Most likely, you will need to pay out of pocket for the tummy tuck while costs for the repair of a hernia would be covered. If no hernia exists, don't expect your insurance carrier to provide any degree of coverage no matter how damaged the muscles are.

Mitchel Krieger, MD
Fairfax Plastic Surgeon
4.0 out of 5 stars 2 reviews

A hard sell

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This smells a lot like a tummy tuck, and insurance will smell it too.  It of course depends on the medical necessity.  This would include hernia etc.  Insurance companies are very difficult.

Scott E. Kasden, MD
Dallas Plastic Surgeon
4.5 out of 5 stars 51 reviews

Insurance covers the muscle, not the tummy tuck.

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Insurance will cover the muscle repair, but not the tummy tuck. The muscle can be repaired without the tummy tuck, so it is separate and considered cosmetic. And usually the insurance does not pay a lot toward the whole procedure. So look at it as a cosmtic procedure (you pay) with a litle help of the insurance company.

G. Gregory Gallico III, MD
Boston Plastic Surgeon
3.5 out of 5 stars 3 reviews

Call your insurance company.

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I have not had any success in getting insurance to cover an abdominoplasty. I always repair the muscles that have spread apart from pregnancy. There is a difference between a true hernia and a diastasis recti.

William B. Rosenblatt, MD
New York Plastic Surgeon
4.0 out of 5 stars 9 reviews

Muscle damage and tummy tuck

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Hi, most insurance plans will only cover hernia repairs in the abdomen. They will not cover surgery for any additional removal of fat or skin. You should see a plastic surgeon to clarify the exact procedure you would need to have done, and at that time your insurance company could determine whether or not this would be covered. Good luck, /nsn.

Nina S. Naidu, MD, FACS
New York Plastic Surgeon
4.0 out of 5 stars 5 reviews

Insurance coverage for abdominal operations

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If the muscle damage has resulted in hernias, then insurance should cover this surgery. If you're looking to tighten the muscles and remove some excess skin and fat, then insurance may deny this as being considered a tummy tuck. However, if you do have a hernia and want a cosmetic tummy tuck at the same time, the insurance coverage will help defray some anesthesia and facility fees. Be sure to check out some before and after photos if you do want a tummy tuck to see what results you can expect.

Jeffrey E. Schreiber, MD, FACS
Baltimore Plastic Surgeon
5.0 out of 5 stars 79 reviews

Insurance coverage after C-section

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Insurance may cover problems associated with a c-section scar. A separation of the muscles is usually not enough to qualify for coverage unless something else is going on. Most commonly if there is a disruption of the anterior abdominal wall otherwise known as a hernia, this would be covered. If the scar was painful, thick and raised such as would occur with a keloid scar this would be covered. Lastly if you are developing a rash under the scar from overhanging skin this may be covered.

With any planned procedure predetermination is necessary to determine benefits of your insurance plan.

Sharon Theresa McLaughlin MD
Long Island City Plastic Surgeon

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.