Can a Diastasis Recti Repair Be Covered by Insurance?

Question

I have a large diastasis recti in my upper abdomen. Sometimes something pushes through the opening and causes great pain and I have to apply pressure until I feel it move back into place (Hernia has been ruled out by ultrasound). Has any surgeon worked with Tricare insurance to get this surgery covered? Core exercises aren't helping and i'm tired of being in pain. I'm in the Bay Area. Any advice?

Shlomo Widder, MD · Answer

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

William T. Stoeckel, MD · Answer

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.

Jourdan Gottlieb, MD · Answer

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.

Norman Bakshandeh Day, MD, FACS · Answer

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

Robert L. Kraft, MD, FACS · Answer

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.

Can a Diastasis Recti Repair Be Covered by Insurance?

Answers (9)