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Why Do Insurance Companies Not Cover Abdominal Diastatis Repair?

I have severe abdominal diastatis from my 2 pregnancies. This starts at my breast bone down below my belly button. Help me understand why insurance companies will not cover the surgery of abdominalplasty. I am 18 months post partum, work out religiously, and my stomach looks worse than right after birth. Not getting this done soon and properly will cause problems in my back, etc for not have the full strength of my core muscles.

Doctor Answers (9)

Rectus diastasis

+2

Most insurance companies do not consider a rectus diastasis to be e true hernia, and they are right.  The will cover the cost of a true hernia repair.  The reason they are so adamant has to do with the fact that many plastic surgeons have abused the system in the past to get insurance companies to pay for a cosmetic procedure.  The insurance carriers have responded by not covering  the procedure even in the most extreme cases.  Frankly, I agree with the insurance companies on this one.

San Diego Plastic Surgeon
5.0 out of 5 stars 6 reviews

If a surgery is for appearance or for self-esteem, it is considered cosmetic by Medicare and insurance companies. That is why tu

+1

If a surgery is for appearance or for self-esteem, it is considered cosmetic by Medicare and insurance companies. That is why tummy tuck is not covered.

To use your words, "my stomach looks worse than right after birth."  The insurance companies know that tummy tuck surgery is for appearance and they do not pay for it.

To word it another way, if a women wants to get abdominal surgery just for the benefit of diastasis or hernia repair and not for appearance, then the repair would be done through a long vertical incision and leave a long vertical scar. Most women would not do this and would instead go for the tummy tuck because they do not want a long vertical scar up and down the abdomen.

Tummy tuck is a surgery to improve the appearance of the abdomen. It is not an insurance procedure.

I hope this clarifies.

Nashville Plastic Surgeon
5.0 out of 5 stars 21 reviews

Insurance coverage for a tummy tuck

+1

Most insurance companies consider a tummy tuck for diastasis repair to be cosmetic.  More data needs to be shown to prove the benefits of a tummy tuck for this condition.

Web reference: http://marylandcosmeticsurgeryinc.com/body-2/tummy-tuck/

Baltimore Plastic Surgeon
5.0 out of 5 stars 61 reviews

Diastasis is not covered by insurance.

+1

Diastasis recti is not covered by insurance companies as they consider this a cosmetic problem.  Unlike hernia, where intestines (bowels) can get stuck and cause medical problem, diastasis would not give functional/medical issue that can be proven scientifically.  

Web reference: http://www.drkimplasticsurgery.com

Houston Plastic Surgeon
4.5 out of 5 stars 36 reviews

Insurance company denial for diastasis repair

+1
This is an excellent question. Insurance companies now have algorithms for denying lots of procedures and, personally, I think that there is a strong link between the number of patents seeking a procedure and the rigor with which the insurer seeks to deny payment. Diastasis is a consequence of pregnancy but that is not why it is being denied. The insurance companies use a standard of functional medical necessity and have supported studies which indicate that diastasis does not impair function. They will pay for a hernia, which can be documented but believe that the results of the diastasis are cosmetic/emotional and do not interfere with activities of daily living. Potential back problems are not the equivalent of actual back problems. If you have orthopedic complaints, then they want the treatment to be orthopedic and not plastic surgery.
New York Plastic Surgeon
5.0 out of 5 stars 8 reviews

Insurance coverage for rectus diastesis after pregnancy

+1

Thank you for your question. Rectus diastesis is a normal consequence after pregnancy in most women. Since it does not cause a functional problem (no scientific study exists), insurance companies do not cover it. Disatesis is not considered a hernia, which is covered by insurance.

Web reference: http://www.bellevueplasticsurgeons.com

Bellevue Plastic Surgeon
5.0 out of 5 stars 7 reviews

Why Do Insurance Companies Not Cover Abdominal Diastatis Repair?

+1

Whether correct or not, the insurance companies consider this a cosmetic procedure as it affects appearance but hasn't been proven to affect function.  (Frankly, there are severe cases where it may lead to back symptoms, but probably in the small minority of cases.)  In a similar fashion, women who have their breasts irreversibly altered by pregnancy and nursing with severe deflation and stretching will not be covered by insurance for a breast lift or breast implants. 

Web reference: http://www.seattleplasticsurgery.com/abdominoplasty-surgery.html

Seattle Plastic Surgeon
5.0 out of 5 stars 66 reviews

Why Isn't A Rectus Diastasis Repaired Covered?

+1

The development of a rectus diastasis is a normal consequence of pregnancy for many women.  It is not a hernia nor a full rip or tear through the abdominal wall and does not cause a functional weakness to the abdomen.  There is no study that shows its repair is going to improve the patient's function other than from a cosmetic point.  Insurance companies will cover procedures that are medically necessary for either life-threatening or  problems that impair the ability to function but not for cosmetic problems.

While diet and exercise are great to get you back to the best shape you can be, some things such as a rectus diastasis are beyond that and may require surgery to correct.

Saint Louis Plastic Surgeon
4.5 out of 5 stars 15 reviews

Why Do Insurance Companies Not Cover Abdominal Diastatis Repair?

+1

The insurance carriers do not consider repair of diastasis to be medically necessary. The reason is that it has no scientifically acceptable evidence that this causes symptoms and that the treatment resolves those symptoms. 

The procedure is considered cosmetic, and I think most surgeons would agree with that. 

Thanks for the question and best wishes.

 

Seattle Plastic Surgeon
4.5 out of 5 stars 28 reviews

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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