Diastasis Recti Repair - Why Won't Insurance Cover It If a Tummy Tuck is Involved?

Question

I'm 35 and 9 months postpartum. I carried twins to 40 weeks. My DR measured 3cm a few months postpartum. I had an appendectomy last month and my DR now measures 3.5 – 4cm. My general surgeon referred me to a plastic surgeon who recommended the repair procedure. I am fit and unconcerned with the small amount of loose skin on my belly, but know that the DR repair goes tandem with a tummy tuck. I've read that that is why insurance won't cover the procedure – the TT is cosmetic – but if DR repair is proven to restore functionality and reduce pain, I don't understand how insurance is able to negate the entire procedure. That said, am I wrong to assume that the effectiveness of the muscle repair HAS been proven? Lots of reviews on here are positive, but most talk about how it looks. If the cosmetic portion of the procedure is significantly less important to me, is this procedure – a major surgery – truly worth the money, pain, and recovery time? Why would a procedure that, in theory, could restore one's body to improve function and quality of life, not covered by insurance? Unless it's not as physically beneficial as it is aesthetically beneficial?

Steve Laverson, MD, FACS · Answer

Excellent points.  In my experience, repair of a wide diastasis, often the result of multiple births and perhaps baseline abdominal wall weakness, consistently offers functional benefit when the patient is suffering.  Not only can the patient perform core exercises better, but I've seen urinary incontinence, back pain, irritable bowel syndrome, posture, and other medical problems significantly improve or completely correct following tummy tuck.  In such cases, I usually reinforce the repair with absorbable mesh, P4HB across the abdomen and plication.

That being said, insurance companies are businesses, and they are in business for profit.  They'll not cover anything they can get out of covering, and what they pay for, they pay as little as possible.  Insurance companies have developed high tech, intensely studied, managed, and executed institutional methods to minimize, avoid, defer, deny, delay, payment, and even to defraud providers without accountability.

If you believe yours should be covered, you may get it covered, but it will likely take a concerted campaign to do so.

Ronald J. Edelson, MD · Answer

U fortunately in the past many plastic surgeons have used diastasis the same as they would hernia and used this to justify a tummy tuck. As a result insurance companies will rarely cover the procedure no matter what and especially if requested by a plastic surgeon.  On the other hand many plastic surgeons don’t want to perform a tummy tuck only to get very poor reimbursement from the insurance company.

Diastasis Recti Repair - Why Won't Insurance Cover It If a Tummy Tuck is Involved?

Answers (2)