Is the Repair of a Permanent Separation of the Rectus Abdominal Muscle a Medical Necessity?

my stomach is shot no control of abs, can barely suck stomach in. I cannot plank. I cannot do situps. I get a horrible cramp in my one ab muscle when laughing too hard or trying to sit up in bed etc. double umbilical hernia repair and emergency c-section caused adhesions (my own diagnosis), deformed me and my tummy plus I have yet t o lose the "baby fat". I need my stomach fixed and it is not cosmetic at all. I need a core to do anything worthwhile.

Doctor Answers 7

Muscle diastasis and medical necesssity

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Hi, rectus muscle diastasis happens in every woman during pregnancy and is not considered a medical condition requiring repair. a ventral hernia on the other hand is a medical condition covered by insurance companies. having both conditions present and how to approach the insurance with them, has to be discussed with your surgeon and your insurance company to learn about your actual benefits and what they are willing to cover.

Medical necessity of abdominoplasty

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I think you should contact your insurance carrier and explain to them your inability to plank and see if they consider this problem a medical necessity.  I suspect they will not.  Everything you describe is in fact cosmetic, however, it may seem medically necessary to you. The changes you describe occur to some extent in all women after pregnancy.

I do think you will benefit from increasing your exercise, strengthening your core and losing the "baby fat" and seeing how you look and feel and then you should consult with a plastic surgeon and see if an abdominoplasty will benefit you 

Thank you for your question.

Medical necessity for abdominoplasty

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You have painted a very compelling picture of many of the problems that a rectus muscle plication may improve with a typical abdominoplasty procedure. But I do not think that today any insurance company will consider those issues to be medical necessities that would allow for coverage of an abdominoplasty procedure. If you have a true ventral wall hernia documented with both a physical exam and CT scan, then insurance will usually cover the hernia repair. But you likely do not have this problem. And the removal of the excess skin would not be covered either. You have described several functional issues, but none that are true medical problems (from an insurance company's perspective). I agree that for you, an abdominoplasty would be a very functionally beneficial procedure. This is a very jaded perspective and maybe not completely accurate, but, an insurance company will likely cover a surgery if it will cost them less to pay for the surgery than they would pay for other services over time if they don't cover the surgery.

Repair of diastasis rectus through a tummy tuck incision is a cosmetic surgery and is not covered.

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Repair of severe diastasis recti with mesh (that is essentially almost a hernia) through an ugly midline incision may be a covered benefit but you will have to check with your insurance carrier.

Repair of diastasis rectus through a tummy tuck incision is a cosmetic surgery and is not covered. It is a procedure for appearance.

I hope this helps.

Ventral Hernia and TT

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Tummy tuck is a cosmetic surgery and is not covered by an insurance agency any where.Ventral Hernia repair is no cosmetic surgery of any kind since leaving it for long time can have complications and is covered by insurance companies.How to manage two issues together should be discussed during your consultation with a PS.

Diastasis Recti Not A Medical Condition

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All women who have a term pregnancy will have diastasis recti to a greater or lesser degree and this is not an indication for your insurance company to cover a tummy tuck.  You could have a ventral hernia, but only the hernia repair (not the TT) would be covered by your insurance.

John Whitt, MD (retired)
Louisville Plastic Surgeon

Medical necessity for tummy tuck

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The term 'medical necessity' is a loaded one, and each insurance plan will have its own determinations. We do know that diastasis is a 'natural' condition of relaxation of the abdominal wall through pregnancy, and is not a true hernia. No insurance plan we know of will recognize diastasis as a medical indication for tummy tuck.

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.