Will Insurance Pay For My Tummy Tuck If I Have Scarring And The Muscles Are Separated?

Q:  I have had 3 c-sections, hysterectomy, and my gall bladder removed that left a large scar. I have a lot of scar tissue that causes me sever pain in my stomach plus I know the muscles in my stomach have separated because you can feel it by feeling my stomach. The scar tissue is attached to my bladder which causes me problems in urination. I also have a large cyst on my left ovary that has added to the pain for the last year. I have a severe amount of skin that hangs from my lower stomach also. My question is since the scar tissue is causing my so much pain in my lower stomach, would it be possible that it would be a surgery that might be covered by my insurance and have the skin removed also.

A: Unfortunately, the simple answer to your question of insurance coverage for a tummy tuck is no. Insurance may cover adhesion release from your bladder and ovarian cyst removal which need to be evaluated and predetermined by your Gynecologist and/or a Urogynecologist. But the skin overhang and its skin removal (tummy tuck or abdominoplasty) will be deemed cosmetic by your insurance company. Similarly, the separation of the muscles (known as rectus diastasis) and bringing them surgically back together is not a medically necessary issue as would be determined by any insurance company that I have ever worked with. This is not to be confusd with a hernia which is a defect in the abdominal wall where bowel may be protruding through, which is a covered procedure.

This may all sound very unfair to you but that is the stark reality of insurance coverages today. There was a day long ago when insurance coverage was more broad and less discriminating but those days have gone the way of the Walkman and the eight track tape. You may even contact your insurance company and they may even say they will provide coverage if the doctor gives a medical reason. (they say anything on the phone but don’t confuse that with what they will really do later…since the person you are talking to will not even be in the section of the insurance company that actually makes the coverage decisions) The only way to know for sure is to send in an actual pre-determination letter which has to be done by the examining plastic surgeon.

Dr. Barry Eppley

Indianapolis Indiana

How Can I Get Insurance To Pay For My Tummy Tuck?

Q: I am interested in and desparately need a tummy tuck. I have checked with insurance and they will cover this procedure if a doctor states that it is medically related. I had a Dr. tell me since I delivered  my baby that my stomach muscles have torn and will not grow back. Do you guys have someone that you can refer me to look at my stomach muscles so I can receive my tummy tuck with my insurance or help with your doctors in your office?

A: Unfortunately, much of your perception about insurance coverage for tummy tucks is inaccurate. No health insurance will pay for a tummy tuck, unless one has a large apron of skin (pannus) that hangs down onto one’s thighs after bariatric surgery. (and even then they deny it most of the time) There is no medical justification or reason for a tummy tuck, it is viewed by insurance as a cosmetic procedure. Despite the fact that your tummy may look the way it does from pregnancy, weight gain or loss, or even surgery, insurance views tummy tucks as having no medical benefit. That can be proven by submitting a pre-determination letter (what anyone says on the phone from an insurance company is worthless about whether they will or will not pay) to seek approval.

Pregnancy does not cause stomach muscles to tear. Rather they cause the vertically-oriented rectus muscles to separate and stay apart, particularly around the belly button area. Sometimes this may be associated with a hernia which insurance usually does cover to repair. But having a rectus diastasis (separation) is not eligible for insurance-covered reconstruction.  

Dr. Barry Eppley

Indianapolis, Indiana