Can a Diastasis Recti Repair Be Covered by Insurance?

Dear BMeds,

    From your description , you have an obvious reducible epigastric hernia, that was not diagnosed by ultrasound study. This is clearly covered by insurance, mainly because of your pain. Unfortunately, The insurance company will not cover the abdominoplasty , only the hernia repair that can be done woth the abdiminoplasty procedure.  So, you will have to bear the cost of the abdominoplasty and submit the hernia repair to your insurance company. Another option for the hernia repair, without an abdominiplasty, is endoscopic repair by a general surgeon . Consult with an experienced board certified plastic surgeon or general surgeon.

          Best of luck,

                                     Dr Widder

I have tried on several occasions to obtain insurance coverage for my patients who have symptomatic rectus diastasis without evidence of hernia...without success. That does not mean that it can not be done, just that it will take the right documentation supplied to the right insurance company. Most insurance companies have a specific clause in their policy that excludes rectus diastasis without evidence of a hernia. Unfortunately, I think that you are going to have trouble getting this covered. 

I know of no one who has been successful in getting one of these covered by insurers. Almost by definition these are not supposed to cause symptoms, the odd one that does is left in the lurch as you seem to be. 

If your surgeon is willing to go to bat for you, a call with your insurer's physician reviewer is the best bet, though in my experience an unlikely winner. 

Thanks for your question, and best wishes. 

I have never heard or have been able to have any insurance carrier provide coverage for a diastsis recti repair.

Although a documented ventral hernia will be covered by insurance, the carriers started limiting their criteria to preclude coverage for diastasis around 4-5 years ago. It is possible that you do have a hernia but preauthorization will require documentation in the form of a CT scan or ultrasound. If you have not had a CT scan to date, this might be a reasonable thing to pursue to clarify the basis for your pain.

Hello,

Thank you for the question.  You may not have a full blown ventral hernia but it does sound like you may have some weakening of the tissue in that area.  Each insurance has their own specific criteria to cover hernias.  Unfortunately, at this point a diagnosis as well as supporting data such as ultrasound or CT scan is the only thing that the insurance has to consider.

All the best,

Dr Remus Repta

Thank you for the question.

Your description certainly fits with the presence of an abnormal wall hernia;  despite the negative ultrasound, I would suggest further evaluation/workup to rule out the presence of the abdominal wall hernia (possibly missed on the ultrasound study).

Although it may be a challenging process, there is a chance that a severe diastasis rect may be a covered benefit through your insurance plan.  Your best bet would be to meet with well experienced board-certified plastic surgeons or in person consultation.  Your plastic surgeon will hopefully be able to document the necessity for surgery and provide this documentation to your insurance company.

 Best wishes.

 

I am sorry that you have this debilitating problem.  Unfortunately, diastasis recti is usually not covered by most insurance programs.  The only hope is to get a peer to peer review from your carrier.  You will need documentation of the problems that you are having in terms of doctor notes etc.  it is helpful to show pictures of your abdomen at rest and with valsalva (bearing down) to demonstrate how your muscle contract ineffectually and can sometimes push your intraabdominal contents outward.  A short video would be excellent.  The most difficult thing is that tricare is sort of like Medicare in that there is no preauthorization process.  Their customer relations will tell you that they will approve procedures that are medically necessary, but will then deny the payment after it has been done.  Lastly, they will ask why a plastic surgeon is doing the procedure and not a general surgeon.  Unfortunately, many of us on this website will nod our heads and say yes, been there tried that and it doesn't work.

If your diagnosis is a hernia vs simple diastasis recti, then insurance may cover the repair of the hernia but not the abdominoplasty.  Donald R. Nunn MD  Atlanta Plastic Surgeon.