Hernia and diastasis detected by physical exam but not in CT-Scan - is this a problem for insurance coverage of hernia repair?
Doctor Answers 4
Insurance coverage for hernia repair
Insurance will almost always cover an umbilical hernia regardless of CT scan report.
Im a hernia specialist. It's all I do. And I've never had any issues with that. They will invariably almost never cover a Diastasis closure.
Abdominal wall Diastasis and Insurance coverage
It is quite difficult to get any insurance company to authorize a Rectus Diastasis repair. This is usually considered by them to be cosmetic, without " medical necessity". However, you do have an umbilical hernia. CAT scans dont always demonstrate small defects that may be obvious clinically. Any hernia which is causing you pain, discomfort, or other associated gastrointestinal symptoms should be addressed sooner than later.
Insurance companies do not deny hernia repairs in general. They do however vary a great deal in what types of clinical evaluations( general surgeons or gastroenterologist) or diagnostic information( CAT scans, ultrasounds,etc.) are required to support a diagnosis.
General surgeons and plastic surgeons often work together in repairing hernias. In some cases the out of pocket cost of an abdominal wall reconstruction(a combined hernia repair and tummy tuck) can be offset by obtaining the appropriate insurance authorization. This is best accomplished by seeking out a team of specialist ( gen/plastic surgeons) who are experienced with these issues.
You should not have a problem getting your procedure( umbilical hernia) covered by your insurance as long as medical necessity is appropriately demonstrated.