Why is Diastasis Recti Repair Not Covered by Insurance?

Question

If I ripped any other muscle in my body, it would be covered by insurance. Why is this not?

It's not simply cosmetic. I have an extremely large gap, which is causing my intestines to press against what's left of my muscle membrane. I have GERD, lower back pain and digestive problems as a result. I understand cutting off excess skin is cosmetic, but this is tender and sometimes painful.

If I had ripped my arm or leg muscles apart in an accident - that would be covered. And neither of those areas house important organs.

Armando Soto, MD, FACS · Answer

Hi there-

	The key distinction to understand in the analogy you make is that rectus diastasis, if left unrepaired, should not be expected to create a worsening disability over time. Therefore its repair is simply (and always) cosmetic in nature.

	I do also agree with Dr. Aldea- what is and what isn't covered by your particular plan has more to do with the contract you signed than with the details of your condition.

	Unfortunately, this is not a case where determination and fight are going to get you anywhere... If you want it fixed, get it fixed... It will cost you some money, but you'll finally look and feel the way you want!

Christopher V. Pelletiere, MD · Answer

The reason that insurance companies do not cover diastasis repair is that you have not torn any muscle in the process. A diastasis is a spreading of the linea alba, which is a very strong fibrous band that runs between your rectus mucles and goes from your sternum to your pubis bone. There is no muscle component to it, and usually has no medical conditions associated with it. After pregnancy, it is very common for the line alba to remain stretched out. There are some people ( pilates instructors), who claim that they can tighten this, but it is not true There is no muscle there, so you may be able to strengthen the rest of your core, but it will have no effect on the diastasis. If the diastasis between the muscles gets wide enough and thin enough, then you can make the argument that it is becoming a hernia, with the intestines, etc. bulging through. However, even this is a tough argument to make. I hope this helps.

Tom J. Pousti, MD · Answer

I have never had an "insurance" entity authorize tummy tuck surgery or plication of the abdominal wall muscles.  In other words, insurance companies do not consider this operation medically necessary.  Best wishes.

Darryl J. Blinski, MD · Answer

Great question. Call your insurance company for their position. Have a PS write a letter of predetermination for you. OR just pay for the operation.

	From MIAMI DR. B

Peter A. Aldea, MD · Answer

"If I had ripped my arm or leg muscles apart in an accident - that would be covered"

	GREAT question but - Answer - not what you want to hear.

	A health insurance policy is in fact a contract between the company and you or your employer. The type and amount of health care costs that will be covered by the health insurance company are specified in advance, in the member contract or "Evidence of Coverage" booklet.

	Each company, as an independent business, has the legal right to decide what it will pay for and what it will not. Similarly, as a consumer you have the right to decide which insurance product you want to buy and which you will not. When YOU signed your contract (Health care policy) you agreed to pay for its listed services. The mere fact that you have an insurance policy does NOT mean that it includes everything and "covers". To make this point clear, each policy has its own long list of EXCLUSIONS - of services are which are not covered. If you buy a plan with an excluded service which you would like to have (such as cosmetic surgery, certain fertility services, certain psychiatric services, certain experimental medical services (IE face transplants etc), it will not be paid for and you are generally expected to pay the full cost of non-covered services out of your own pocket.

	However, unfair or distasteful it may seem. There is nothing wrong with getting what you paid for.

	But - many doctors have a real issue when insurance companies do not pay for "covered" services which they are SUPPOSED to pay for. This is frequently a problem as well and one that we need to vigilantly fight.

	At present, cosmetic surgery is NOT paid for/covered by ANY insurance plans. It is clearly excluded and this is made clear when you purchased the plan. Putting the tummy muscles together is a cosmetic operation to make you look better. You therefore have a choice of not having or having it and paying for it yourself.

Marcus L. Peterson, MD · Answer

I think there are times when there would be some mechanical and or functional improvement by repairing the diastasis recti.  It is a normal occurrence with pregnancy and abdominal wall stretch.  The best thing you can do short of surgery is to strengthen and tone your abdominal muscles.

	I encourage you to discuss this with your insurance carrier and see if they have any provisions for the correction of the diastasis.  Next time you change insurance carriers, try to find one that has coverage for this type of surgery.

	Best Wishes.

Robin T.W. Yuan, MD · Answer

Diastasis recti is a separation of the recti abdominus muscles and is a normal, expected consequence of normal pregnancy. There is usually no functional disability unless a true hernia has also occurred or there is extreme diastasis.

John Whitt, MD (retired) · Answer

Diastasis recti is as has been previously pointed out a normal consequence of pregnancy. It would be unusual for a diastasis to cause pain or other symptoms. If you could convince your insurance company that you do have pain as a result of the diastasis, they might be willing to cover the repair. However, this is only a small part of the tummy tuck procedure and they definitely would not cover the remainder of the procedure.

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