Diastasis Recti denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for reconstructive abdominoplasty for treatment of the enrollee’s diastasis recti. Findings: The physician reviewer found that this patient presents with an abdominal bulge, abdominal pain, weakness and back pain attributed to a documented large diastasis recti of the abdomen. Work-up of other potential causes of her abdominal condition have not been able to identify a cause other than the diastasis recti. This has included multiple CT scans and plain radiographs. In addition, her condition has appeared to have worsened as the most recent CT evaluation noted the presence of the transverse colon within her protuberance. The repair of diastasis recti is not generally considered to be a functional treatment but can be an integral part to cosmetic procedures, namely abdominoplasty.

A 50-year-old female enrollee has requested surgical correction of diastasis recti for treatment of her medical condition. Findings: The physician reviewer found that the patient’s records describe the patient to have abdominal pain, which may constitute an abnormal state from some structure or disease process that has not yet been fully diagnosed. Umbilical hernias can cause abdominal pain as suggested by the patient’s primary care physician but a thorough abdominal examination has not been well documented. The patient’s weight and height could be considered an overweight condition. Thus, there could be an abdominal pannus contributing to the patient’s pain and referral to a plastic surgeon may help diagnose this patient’s condition.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical procedures. According to medical study guidelines, when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient’s appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. Similarly, in the case of skin laxity requiring resection with a panniculectomy, the authors reported that “A panniculectomy must meet specific criteria to be medically necessary. The pannus must hang below the level of the pubis and be confirmed with photography. Patients must fail medical treatment of intertrigo for three months. Medical treatment includes good hygiene, topical antifungals, corticosteroids, and antibiotics.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for muscle, myocutaneous, or fasciocutaneous flap trunk; excision, excessive skin and subcutaneous tissue (includes lipectomy); other area; insertion, drug-delivery implant (i.e., bioresorbable, biodegradable, non biodegradable). A muscle, myocutaneous, or fasciocutaneous flap trunk procedure is used for rectus diastasis repair to narrow a fascial gap between the rectus abdominus muscles. One study reports that diastasis recti abdominis is characterized by the lateral deviation of the two abdominal rectus muscles. The authors note that patients with diastasis recti abdominis report several symptoms including lumbopelvic pain, abdominal weakness, urinary incontinence, and issues with self-esteem.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving diastasis recti, then check the rights and deadlines that apply to your plan.