TT w/ MR medically necessary if it's to help strengthen ab muscles after spinal fusion and improve urinary incontinence?

Question

I have undergone spinal fusion along with 2 other surgeries on my lumbar spine. In addition, I have some urinary incontinence due to childbirth. Is there a chance that this would be covered by FMLA? I know cosmetic surgeries are not typically covered, but if it's related to an underlying health condition, it may be. Is there a chance it would be covered? Should I be asking my orthopaedic surgeon, my plastic surgeon, or both for a medical certification?

Anita Patel, MD, FACS · Answer

Unfortunately, repair of diastasis recti is not considered medically necessary by insurance, and last I checked there isn't even a CPT code (used to bill insurance) specific to that procedure. Diastasis repair is not the same as a hernia repair, and while it is typically considered part of an abdominoplasty (tummy tuck), insurance does not cover abdominoplasty since it is seen as a strictly cosmetic procedure. (The closest procedure they cover is a panniculectomy, but a diastasis repair is not part of that procedure anyway.) Even though patients often say they notice less back pain after a tummy tuck, it is not considered a treatment for back pain. Also, tummy tuck and/or muscle repair are not considered treatments for urinary incontinence. I don't think there is any chance of it getting covered, even if your doctors write notes saying they feel it may help.

Christian Arroyo, MD · Answer

There are definitely benefits to having an abdominoplasty other than a smaller waist and tighter abdomen!! This is a great question!! Having an abdominoplasty will definitely help with stress incontinence because it will assist in strengthening your core muscles which in turn help to strengthen your entire abdominal area along with pelvic floor. It is unlikely that insurance will cover this procedure because it is considered a cosmetic procedure. You can however submit this for preauthorization to see if they will cover it. This procedure should be performed by a plastic surgery as it is a specialized procedure. Best of luck!

Curtis Wong, MD · Answer

this should not be covered by any third party.  You can certainly check with your insurance to see if it is covered and if so, then you must find a surgeon/physician that will attest that your problems are truly reversible with a tummy tuck and muscle repair... and document in your exam your deficiencies.  Then authorization must be pursued and do not be surprised that they still reject this, even after having told you it was 'covered'.  If you really want this done, its much easier to have this done cosmetically and you can pick your surgeon and also shop around for better costs.

Adolfo Sesto, MD · Answer

Hi. I do not think insurances cover plastic surgery procedures in any part of the world, you should consult your neurosurgeon or orthopedic to ask them for an indication of the surgery as part of your treatment for improving your condition. But I do not know if this will work.
International Member of the American Society of Plastic Surgeons (ASPS)
Member of the International Society of Aesthetic Plastic Surgery
25 years experience

Camille Cash, MD · Answer

Tummy tucks with or without muscle repair are considered cosmetic and not covered by insurance.  This is true even if there are underlying conditions as there are other medical interventions to address those issues (spinal fusion, bladder sling, etc.).  If you are interested in the a tummy tuck I encourage you to meet with a board certified plastic surgeon in your area to learn more.

Jon Ver Halen, MD, FACS (license suspended) · Answer

Dear BadJuju,Hello and thank you for your excellent question.  My first suggestion for you is to check with your insurance company, to see if they would be willing to cover this.  If the answer is yes, then it would be reasonable to discuss it with your surgeon(s). It is best to answer your question during a face-to-face evaluation, when you can discuss your goals and expectations for the procedure, and you can have a physical examination to evaluate for that procedure. I recommend that you find a board-certified, or board-eligible plastic surgeon with whom you are comfortable. Be sure to have all of your questions answered during a face-to-face meeting with your surgeon, and review before and after pictures of similar patients whom have had this procedure. If you have any questions, call our office for assistance. Good luck!
  
Best,
  
Jon Ver Halen, MD FACS
  
Harvard educated plastic surgeon
  
Texas “Top Doc” 2017, 2018
  
RealSelf100
  
America’s Top Plastic Surgeons, Consumer’s Research Council, 2010 – 2018
  
BeautyAdvisor Top Contributor

TT w/ MR medically necessary if it's to help strengthen ab muscles after spinal fusion and improve urinary incontinence?

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