Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectus Diastasis
Issue under review: Excess skin removal and tummy tuck

Determination:
The Excess skin removal and tummy tuck is not medically necessary.

The patient is an adult female. She had a large ventral hernia.  She complained of core weakness and inability to use her abdominal muscles effectively.  She had an abdominal bulge.  Physical therapy did not improve her symptoms.  Her surgeon recommends abdominoplasty and rectus repair.

Per the ASPS Position Paper, "A true hernia repair involves opening fascia and/or dissection of a hernia sac with return of intraperitoneal contents back to the peritoneal cavity.  A true hernia repair should not be confused with diastasis recti repair, which is part of a standard abdominoplasty."  

The patient's surgeon did not define fascial edges, did not enter the peritoneal cavity and did not resect a hernia sac.  He repaired a diastasis recti.  True hernias require repair due to the risk of bowel incarceration or strangulation.  In contrast, diastasis recti is a spreading of the rectus muscles without a true hernia.  Bowel incarceration or strangulation cannot occur with diastasis recti, because the fascia is intact.  Diastasis repair with abdominoplasty is a cosmetic procedure that does not improve health or function.  

Per Dr Golladay, MD, "Diastasis recti or a widened linea alba has no significance." 

Per Sabiston, "The rectus abdominis muscles are held close together near the anterior midline by the linea alba.  The linea alba itself has an elongated triangular shape and is based at the xiphoid process [tip] of the sternum.  The linea alba narrows considerably below the umbilicus so that the medial edge of one rectus muscle may actually overlap the other.  The most common variant of normal anatomy seen in the abdominal wall is diastasis recti.  This consists of an upper midline protrusion of the abdominal wall between the right and left rectus abdominis muscles.  This abnormality...does not require treatment unless an epigastric hernia occurs in association with the diastasis recti...Patients or their families need to be counseled about the innocuous nature of the abnormality." 

Per Hickey et al, "Patients and physicians should be advised that correction (of diastasis) is largely cosmetic, and...they do not carry the same risks of actual herniation."  Per Akram and Matzen, "Rectus diastasis is by itself not a true hernia...Repair is mostly done due to cosmetic reasons.  The condition does not necessarily require repair, and conservative management may be an alternative.  If done, the protrusion of the abdomen, rather than the diastasis itself should influence the decision of repair."  

Per a study of abdominoplasty patients, "No significant differences in trunk muscle endurance, lung function, or self-rated physical function were found after abdominoplasty with vs without plication."  

Plication of the rectus muscles is not established in the medical literature to be of functional benefit.  Diastasis repair is part of a cosmetic abdominoplasty, the purpose of which is to flatten the abdominal wall and improve abdominal contour.  Staalesen et al "concluded that the quality of evidence of positive health effects for patients having abdominoplasty is very low concerning all studied outcomes."  

Abdominoplasty with diastasis repair is a body contouring rather than a functional operation, and is cosmetic for this patient.  Therefore, it is not medically necessary.