Muscle repair and hernia repair. Why won't insurance cover both?

Question

I've had 3 kids and am in my 3rd hernia. I have yet to have this one repaired because of the cost. I have a severe abdominal wall separation. If the muscle repair would prevent future hernias why won't the insurance pay for it? How do I appeal successfully?

Michael Constantin Gartner, DO · Answer

Muscle repair is considered to be a cosmetic procedure which is why most insurance providers won't cover that. You can probably get your hernia repair covered, though.

Lewis Albert Andres, MD · Answer

Hello!  Thank you for your question!  It is unlikely that you have a true hernia, which is a defect in your fascia, with a direct connection from within your peritoneal cavity out through this fascial defect.  A diastasis recti is more likely, which is widening of the midline. This is the intended purpose of the abdominal wall during childbearing, for which it usually returns to the anatomic midline afterwards. When there is a widening, it is termed diastasis recti.  This never warrants insurance coverage, since there is no functional consequence from this.  As physicians, we are also obligated not to pursue anything that is purely cosmetic through insurance.  While rectus plication is certainly an option with/out a tummy tuck, these procedures would be aesthetic in nature and not covered by insurance.  Insurance companies are kern on this, which is why it is routinely denied and often there is an exclusion criteria with this.   If a true hernia does exist, documentation, imaging proof, examination, as well as detailed review of your complaints will be needed.  Hope that this helps. Best wishes.

Robert J. Spies, MD · Answer

Hello and thanks for this question.  One that people do ask frequently.  As a plastic surgeon for 28 years, I have not had any insurance company reimburse for abdominal wall muscle separation.  That is a condition where the rectus muscles stretch apart from pregnancy or weight gain for other reasons.  A true hernia is a hole in the fascia that allows bowel or fat from inside the belly to protrude.  Those are covered by insurance companies.  I am not sure you can convince an insurance company that tightening the rectus muscles (which is done during a tummy tuck) helps prevent a hernia.  It is possible to have the hernia repair and a tummy tuck at the same time.  However, you would have to pay for the tummy tuck part and any costs for anesthesia and operating room during that time only.

Luis Macias, MD, FACS · Answer

Insurance companies do not cover diastasis recti (separation of abdominal muscles) but will cover true hernias like an umbilical hernia repair (belly button). A true hernia is a defect (a hole) of the abdominal wall, which can be dangerous if an intestine gets stuck and the blood supply is compromised. This can lead to the intestine dying and a complicated surgical and medical course. Diastasis recti does not have this risk since it is a speration of the muscle and not a true hole in the abdominal wall, thus the insurance companies do not deem it a medical necessity.

Jason Mussman, MD · Answer

Thank you for the question!  You mentioned that you are on your third hernia.  Have you had repairs in the past?  If you need a hernia repair and you have separation of the abdoinal musculature, you can have both repaired simultaneously.  However, insurance does not cover tightening of the musculature which is cosmetic.  Best of luck.- Dr. Mussman

Muscle repair and hernia repair. Why won't insurance cover both?

Answers (8)

Answer: Hernia versus diastasis recti

Answer: Hernia versus diastasis recti

Answer: Muscle repair and hernia repair. Why won't insurance cover both?

Answer: Muscle repair and hernia repair. Why won't insurance cover both?

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Muscle repair and hernia repair. Why won't insurance cover both?

Answers (8)

Answer: Hernia versus diastasis recti

Answer: Hernia versus diastasis recti

Answer: Muscle repair and hernia repair. Why won't insurance cover both?

Answer: Muscle repair and hernia repair. Why won't insurance cover both?

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Recommended reading

Everything you need to know about Tummy Tuck

Our mission is to create a world where every investment in modern beauty is Worth It.