I Have Had 5 Pregnancies, with One Being Quintuplets. I Am Fight my Insurance About Getting my Muscle Walls Fixed. Suggestions?

Since my insurance wont pay, I cant afford to get all of it fixed on my own. What should I get fixed immediately and is there anything I can do to help. I have a hard time getting out of my bed due to lack of muscles in my stomach. My back hurts all the time since its doing the work that my stomach muscles should do. I get infections due to the flap being so long and it rubbing. I have done physical therapy and they said until I get my muscles fixed, they cant help. I am lost and needing relief.

Doctor Answers 6

Tummy Tuck - 5 Pregnancies, with One Being Quintuplets. Fight with my Insurance About Getting my Muscle Walls Fixed.

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Each insurance policy has its own specific requirements and conditions as to (1) which procedures are "covered," and (2) what the extent of that coverage is.  It has become increasingly difficult to obtain reimbursement or coverage for a procedure such as this but it is hard, without knowing the specifics of your coverage, to try to advise you on how to proceed.  In general, though, the more significant the pain or debilitating symptoms, the greater the likelihood that you may be able to get at least part of your procedure covered.  I would advise working with a plastic surgeon and a general surgeon.  In the event that you can document the extent of your disability and even more so if a true hernia is diagnosed, you may yet have some success.  Short of that, you can contact the Plastic Surgery department of a nearby medical center; reduced rate procedures are often available there.  In that case, the surgery is typically performed by senior surgical residents or fellows (in the last year of their training) under the supervision of attending surgeons.  That may turn out to be the best solution.

I hope that this helps, and good luck,

Dr. E

Insurance does not pay for repair of diastasis recti

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Unfortunately, insurance does not pay for repair of diastasis recti, only for true hernia formation. Muscle repair at the time of tummy tuck will usually fix the problem.

J. Jason Wendel, MD, FACS
Nashville Plastic Surgeon
5.0 out of 5 stars 221 reviews

Insurance Will Not Cover Repair Of Muscle Separation

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Unfortunately, the days have long past when insurance will cover repair of a rectus diastasis or midline muscle separation. While this is an integral part of most tummy tuck surgeries, it is not considered a medically necessary procedure unless there is a documented umbilical hernia through the muscle separation. You will have to seek a tummy tuck with muscle tightening done as a cosmetic procedure.

Insurance and diastasis

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It is now very difficult to get insurance to pay for repair of a diastasis or excessive skin after pregnancies. However, I wouldn't say never. You should see a board certified plastic surgeon who can attempt to preauthorize the case and, if the insurance company denies, they will be required to explicitly state the reason for the denial, which can be appealed. I am not optimistic but, it is your insurance and if you are willing to do the work to fight for a procedure, you may be successful. That said, insurance will not pay for a tummy tuck and, if they agree to pay for the diastasis and you want additional surgery, then you would be financially responsible for the rest of the procedure.

Insurance Company Unlikely To Help With Muscle Repair

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It is very unlikely that your insurance company will cover the muscle repair of your diastasis recti.  If you cannot afford the cost of a tummy tuck, check with the Resident's Clinic at U. of L.  They might be able to perform your surgery at a reuce4d cost.

John Whitt, MD (retired)
Louisville Plastic Surgeon

Getting a tummy tuck covered by insurance.

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When I was a medical student in 1985 we saw the tail end of a time when the insurance companies would cover the repair of the separation of the abdominal muscles after childbearing known as Diastasis Rectus.  Since that time I have seen very few people succeed in getting coverage.

In this day and age healthcare dollars for elective and semi elective surgeries  continue to shrink.  The same is true for procedures such as elective breast reduction.

I think you'll have an uphill battle trying to get your surgery covered but if you're going to try all you need to establish a medical history that will help you to achieve your goals.  Supporting documentation about your  back pain, difficulty with hygiene and disability  will need to be clearly laid out .  Essentially, you will need to prove a medical necessity.

Even with the right documentation it's still tough to get these things covered nowadays.  Before you go to the trouble you may wish to double check the fine print in your contract with your healthcare company.  Many of them very specifically exclude procedures such as this.

 I wish you luck on your quest and I hope that you're successful.

Adam Tattelbaum, MD
Washington DC Plastic Surgeon
5.0 out of 5 stars 115 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.