Hernia and diastasis detected by physical exam but not in CT-Scan - is this a problem for insurance coverage of hernia repair?

I have been to both a gastro and a board certified plastic surgeon who both felt diastasis recti and a small umbilical hernia. I am also seeing a general surgeon next week ( to coordinate with plastic surgeon to fix hernia and diastasis at same time) I know the diastasis is not covered but that the hernia repair part should be - since the ct scan did not show the hernia is that going to be a problem for insurance coverage or is the physical exam of the doctors enough to give coverage of hernia

Doctor Answers 3

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. 

Miami Plastic Surgeon
4.7 out of 5 stars 14 reviews

Hernia repair

Hernias are not always picked up on CT.  But they can be diagnosed by physical exam.  If a surgeon diagnoses a hernia by exam and repairs it during surgery it should be covered by insurance regardless of the CT.

Lawrence Rosenberg, MD
Lutherville Timonium Plastic Surgeon
4.7 out of 5 stars 14 reviews

Hernia and diastasis

Understand that the hernia repair is one of the lowest paying procedures and insurance will not cover 3+ hours of anesthesia time for what they know is a 15 minute case.  

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.