My OBGYN and primary doctor were convinced that the big bulge between my belly button and my breast bone was a hernia. A general surgeon performed a physical examination. In his opinion, the bulge is a severe diastasis recti and not a hernia. He recommended several reconstructive surgeons (Houston) but none are interested in working with Aetna to have this operation covered. Aetna says the surgeon must prove this is a medical operation and not cosmetic. How do I find such a surgeon? Please help!
Looking for a Surgeon Who Will Work with Aetna to Repair a Severe Diastasis Recti...Realistic or a Lost Cause?
Doctor Answers (5)
insurance companies are not in the business of providing medical care. they only make money when they refuse to cover medical care. No one will cover this procedure
Will insurance cover a diastasis
Unfortunately, a diastsis is not a true hernia, and as such poses you no medical risk. Aetna or any other medical insurance measures care coverage according to "medical necessity" and diastasis is not on the list.
Web reference: http://www.peterejohnsonmd.com/tummy-tuck
Looking for a Surgeon Who Will Work with Aetna to Repair a Severe Diastasis
I'm afraid this probably is a lost cause. Diastasis rectus is usually considered a cosmetic problem without any symptoms or medical complications. I have never seen a patient get insurance coverage for this problem. Most surgeons that I now have tried and failed to assist patients with this problem with their insurers.
I'm sorry that I can offer more encouragement. Best wishes
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Insurance coverage of a diastasis
Unfortunately most insurance companies will not cover repair of diastasis recti, the separation of your two central abdominal muscles. This usually is caused after pregnancy wen the muscles do not go back together. This leaves a separation that can allow your "insides" to bulge outward, especially when sitting up. There can be mild discomfort but because there is not any true hernia (hole) thee is not really a safety issue, and therefore is usually not "medically necessary". You might try one of the resident training programs where the program might allow pro bono work to be done.
Web reference: http://www.cosmeticsurgerybaltimore.com/
Basically if there is no medical indication (no symptoms) then procedures are considered cosmetic. You would need to find a surgeon who will lie to the insurance company. I do not know anyone who is willing to do that. It is unethical. Aetna is very hard to deal with.
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.
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