Can Diastasis Recti and a Hernia Repair Be Covered Under Insurance Depending on Your Doctor and CPT Code?
- Asked by KimberlyFoster in Round Rock, TX
- 6 months ago
31 yr old female with 2 children (2009, 2011). 93 lbs/active. I have a substantial separation in abdominal wall and an umbilical hernia the size of a golfball. I have contacted my ins. provider and they will not cover any repair to my abdominal wall unless it is to repair the hernia alone. Seems odd to me considering a hernia may occur again later due to the separation. Are there any doctors that will repair the separation and the hernia simultaneously with a CPT code that fits the insurance guidelines?
Hernia yes, diastasis not usually
Many years ago when insurance was less restricted than now I did try repeatedly to get approval for coverage for the worst diastasis I have ever seen. It was declined even with the help of her ob-gyn pleading her case. I doubt you can legitimately have this covered by your insurance. Hernias are different and can cause bowel obstruction therefore are typically covered. These are mostly taken care of by general surgeons. When hernias are repaired by the plastic surgeon during abdominoplasty, some may credit the reimbursement for the hernia towards your tummy tuck but typically it is a very small fraction of the cost of a tummy tuck by an experienced board certified plastic surgeon. In my practice (100% cosmetic, no insurance work) I just repair the hernia free of charge since it only takes 5 minutes with the normal exposure with a tummy tuck. Patients are given the op report and codes and can try to get some reimbursement if they wish. I cannot speak for how others manage these cases but I'd say do not be optimistic that insurance will be much help with the repair of rectus diastasis.
Insurance coverage for diastasis repair is spotty, but hernia repair is usually covered
Each insurance company has its own criteria and list of covered procedures, and if they have rendered that opinion, then it is their policy in general. It is very difficult to get insurance companies to cover diastasis recti, even in the presence of a hernia, because most consider that to be a strictly cosmetic procedure. Even if the hernia is done in the context of an abdominioplasty, which I often do as an incidental procedure, it won't be covered even as a hernia repair because the abdominoplasty is considered the reason for the procedure. There is an ICD -9 code and a CPT code for diastasis and its repair respectively, but this means nothing when it comes to a specific insurance carrier's decision about authorization. This is a very frustrating situation, I'll agree 100%, but then again, most insurance companies are there to make a profit and not really help you, and as such they are often very frustrating. My advice is to consider what your priorities are: do you simply want/ need your hernia repaired and don't care about the appearance of your abdomen, or do you want improvement in the contour of your tummy. If it's the former, go with the insurance covered hernia repair only. If the latter, just accept the reality and do what most women do in this situation, and find a board certified plastic surgeon you trust and have the abdominoplasty, which should include repair of the hernia at the same time.
Hernia Repair, Correction of Diastasis, Tummy Tuck Surgery?
Thank you for the question. Based on your description, it sounds like you are an excellent candidate for abdominal wall contouring surgery. There is a greater chance than not that the hernia repair will be covered through health insurance. In my experience, insurance companies will not cover correction of diastasis recti.
I hope this, and the attached link, helps.
Difference between hernia and diastasis recti
First, I think it is important to make sure you understand the terms used. I like to explain to my patients that the abdomen has four layers, that being skin, the fat layer, the abdominal muscle layer and then all of the internal organs inside of it. A hernia is simply an actual hole in the muscle layer, most commonly around the bellybutton as in your case. This is a natural weak spot in the abdominal wall, and most likely your two pregnancies stretched that hernia open. Insurance companies will cover a hernia repair because at best they will stay the same in size and not close down in an adult or more likely will continue to enlarge which makes it a more complicated repair. Insurance will cover this because of the well-known complication of having some of the internal organs such as intestine or omentum slip through that abdominal wall hernia (hole), get twisted and caught there and then lose their blood supply. This becomes a surgical emergency potentially even life threatening.
Diastasis recti on the other hand does not include an actual hole in the abdominal wall. What happens is before pregnancy the two main muscles called rectus abdominis that travel from the lower ribs to the pubic bone are separated by only a few millimeters. However, with the two pregnancies, these can be stretched much further apart such that when you try to do an abdominal crunch, this stretched out area will bulge in a vertical line the length of the abdomen. Since there is no hole in it, however, there is no threat of tissue becoming entrapped and dying, and therefore, it is regarded by the insurance companies as a cosmetic problem and not a life-threatening problem. We have never had success in getting insurance to cover that.
You may want to talk to your surgeon, and if you are a candidate for abdominoplasty (tummy tuck) repair of the diastasis recti is a feature of that, and he may be willing to use proceeds from the umbilical hernia repair to help defray some of the cost.
Best of luck to you.
There is no insurance company that covers a diastasis recti repair. Hernias are usually covered.
The answer you got from your insurance is exactly what I would expect. they will pay for a true hernia such as an umbilical hernia, but not much. Insurance companies are wise to the rectus diastasis ruse, no matter how severe or symptomatic it is.
Insurance Coverage of Diastasis and Hernias
Most insurance companies will cover the repair of a hernia but not a diastasis. The diastasis is a normal finding after childbirth or weight loss. It is merely stretch of the midline fascia (the tough tissue that holds your insides in). A hernia is a hole in the fascia. The hole was probably there already and just enlarged over time. A diastasis rarely leads to hernias, so the likelihood of developing a recurrence after the hernia repair is no different in someone with or without a diastasis. The CPT codes are designed to describe what was done. Any manipulation of them to get a tummy tuck covered is considered fraud. I have done two patients with very large hernias during abdominoplasty in the last two weeks. On both we billed the insurance only for the hernia repair (the significant extra time required to repair the hernia above the normal time for an abdominoplasty, i.e., only what the insurance company would normally cover), not the diastasis repair and the patient paid for the tummy tuck. Had the hernia repair not taken extra time, we would have simply repaired it and not billed for it since the repair was incidental to the tummy tuck, the primary procedure. If you cannot afford the abdominoplasty, have the hernia repaired to prevent problems and save for the tummy tuck at a later time.
Diastasis Recti and Umbilical Hernia and Insurance Coverage
Unfortunately, most health insurance companies view repair of diastasis recti (or separation of the abdominal muscles following pregnancy) as a cosmetic procedure (not medically necessary). However, they usually will cover the cost of an umbilical hernia. If the diastasis is extremely severe or causing discomfort, you could ask your surgeon to appeal their decision. Best wishes.
Web reference: http://www.vincentleporemd.com
Baby Damage to the Abdominal Wall
In my experience in San Antonio Diastasis Recti has not been covered by insurance. It is considered a cosmetic procedure. The umbilical hernia, however, is routinely covered. I would recommend seeing a Board Certified Plastic Surgeon near you and if the surgeon feels it is justified try to get authorization for insurance reimbursement.
Can Diastasis Recti and a Hernia Repair Be Covered Under Insurance
There is no code for Diastasisi Recti that is recognized by insurance companies. The umbilical hernia repair is another matter. Your surgeon can repair the umbilical hernia and bill for it. He can then continue the operation for the rectus repair but that will be up to you to pay for. The umbilical hernia repair and the diastasis repair are two totally different parts of the procedure even though they are done during the same anesthesia.
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.