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

Question

31 yr old female with 2 children (2009, 2011). 93 lbs/active. I have a substantial separation in abdominal wall and an umbilical hernia the size of a golfball. I have contacted my ins. provider and they will not cover any repair to my abdominal wall unless it is to repair the hernia alone. Seems odd to me considering a hernia may occur again later due to the separation. Are there any doctors that will repair the separation and the hernia simultaneously with a CPT code that fits the insurance guidelines?

Warren Schutte, MD · Answer

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.

Ronald J. Edelson, MD · Answer

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.

Rigo J. Mendoza, MD · Answer

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.

Vincent N. Zubowicz, MD · Answer

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.

Robert D. Wilcox, MD · Answer

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.

Norman Bakshandeh Day, MD, FACS · Answer

There is no insurance company that covers a diastasis recti repair. Hernias are usually covered.

Suresh Koneru, MD · Answer

In my experience in San Antonio Diastasis Recti has not been covered by insurance. It is considered a cosmetic procedure. The umbilical hernia, however, is routinely covered. I would recommend seeing a Board Certified Plastic Surgeon near you and if the surgeon feels it is justified try to get authorization for insurance reimbursement.

Jeffrey Zwiren, MD · Answer

Insurance company coverage certainly varies from one company to the next. Coverage is completely out of the control of the plastic surgeon. We are the third party, the contract is between you and them. If you think you have a legitimate claim then call the insurance company ask to speak to a claims representative and they can review your contract and give you some indication if you should proceed.

Karol A. Gutowski, MD, FACS · Answer

While repair of umbilical hernias is normally covered by insurance, a diastasis repair typically is not. There is no way to make it covered and still be honest and ethical. In rare cases, if pain can be attributed to a diastasis, I have seen it covered.

Joseph L. Grzeskiewicz, MD, FACS · Answer

Each insurance company has its own criteria and list of covered procedures, and if they have rendered that opinion, then it is their policy in general. It is very difficult to get insurance companies to cover diastasis recti, even in the presence of a hernia, because most consider that to be a strictly cosmetic procedure. Even if the hernia is done in the context of an abdominioplasty, which I often do as an incidental procedure, it won't be covered even as a hernia repair because the abdominoplasty is considered the reason for the procedure. There is an ICD -9 code and a CPT code for diastasis and its repair respectively, but this means nothing when it comes to a specific insurance carrier's decision about authorization. This is a very frustrating situation, I'll agree 100%, but then again, most insurance companies are there to make a profit and not really help you, and as such they are often very frustrating. My advice is to consider what your priorities are: do you simply want/ need your hernia repaired and don't care about the appearance of your abdomen, or do you want improvement in the contour of your tummy. If it's the former, go with the insurance covered hernia repair only. If the latter, just accept the reality and do what most women do in this situation, and find a board certified plastic surgeon you trust and have the abdominoplasty, which should include repair of the hernia at the same time.

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

Answers (16)

More Tummy Tuck Questions

Question About Having Crohn's Disease and Wanting a Full Tummy Tuck?

Just Did a Tummy Tuck, I'm Not Flat Why is It?

Had a Full Tummy Tuck Wth Muscle Repair. How Soon Can I Go Surfing?

Why is There a Lump Line in my Upper Abdomen? (Photo)

Is a Tummy Tuck the Only Way to Alleviate Pain Caused by Skin Hanging over C-section Scar?

Hernia? After Full Tummy Tuck? (photo)

WE SEND PRETTY
EMAILS