Can Diastasis Recti and a Hernia Repair Be Covered Under Insurance Depending on Your Doctor and CPT Code?

Insurance companies typically cover hernia repairs (umbilical, inguinal, ventral) but will not cover diastasis recti as that condition is not a true hernia.   In office we commonly repair small umbilical hernias at the same time as an abdominoplasty but any larger hernia requiring extensive repair and/or mesh would need to be corrected by a general surgeon first. 
Good luck in the rest of your research and decision making with your repairs. 

The answer you got from your insurance is exactly what I would expect.  they will pay for a true hernia such as an umbilical hernia, but not much.  Insurance companies are wise to the rectus diastasis ruse, no matter how severe or symptomatic it is.

I have been in practice 14 years.  Insurance will cover an umbilical hernia repair but I have never had them approve coverage for diastasis of the rectus muscles.  Trying to get insurance to pay for a diastasis repair under a different code is considered insurance fraud.

Abdominal wall hernias are usually covered by insurance but diastasis, which is a wide separation between the two rectus muscles, is usually not. You can call your insurance broker to find out.

Dear Kimberly,

First, I think it is important to make sure you understand the terms used. I like to explain to my patients that the abdomen has four layers, that being skin, the fat layer, the abdominal muscle layer and then all of the internal organs inside of it. A hernia is simply an actual hole in the muscle layer, most commonly around the bellybutton as in your case. This is a natural weak spot in the abdominal wall, and most likely your two pregnancies stretched that hernia open. Insurance companies will cover a hernia repair because at best they will stay the same in size and not close down in an adult or more likely will continue to enlarge which makes it a more complicated repair. Insurance will cover this because of the well-known complication of having some of the internal organs such as intestine or omentum slip through that abdominal wall hernia (hole), get twisted and caught there and then lose their blood supply. This becomes a surgical emergency potentially even life threatening.

Diastasis recti on the other hand does not include an actual hole in the abdominal wall. What happens is before pregnancy the two main muscles called rectus abdominis that travel from the lower ribs to the pubic bone are separated by only a few millimeters. However, with the two pregnancies, these can be stretched much further apart such that when you try to do an abdominal crunch, this stretched out area will bulge in a vertical line the length of the abdomen. Since there is no hole in it, however, there is no threat of tissue becoming entrapped and dying, and therefore, it is regarded by the insurance companies as a cosmetic problem and not a life-threatening problem. We have never had success in getting insurance to cover that.

You may want to talk to your surgeon, and if you are a candidate for abdominoplasty (tummy tuck) repair of the diastasis recti is a feature of that, and he may be willing to use proceeds from the umbilical hernia repair to help defray some of the cost.

Best of luck to you.