Breast reduction requirements under the Empire Plan break down into two broad categories: medical necessity and Schnur scale calculations. In our office, Dr. Harris handles the medical necessity component by evaluating if breast reduction surgery will resolve a qualified medical condition, while I handle Schnur scale breast reduction requirements. If you’re considering breast reduction surgery, this is what you need to know about qualifying for insurance coverage.
What Is the Schnur Scale? Breast Reduction Criteria
Insurance companies look at breast reduction cases in one of two ways: whether the surgery is cosmetic or medically necessary. While cosmetic surgeries are not covered by insurance, medically necessary ones are. In the past, one of the biggest challenges with breast reduction surgery was determining just that—when it was medically necessary versus when it was cosmetic. As a result, many women who needed breast reduction surgery to resolve chronic conditions struggled to get it covered by their insurance.
The Schnur sliding scale was a study compiled by plastic surgeons that used the amount of breast tissue to be removed compared to the patient’s body surface area as an objective measure of medical necessity. Specifically, this study showed that all women who fell into the 22nd percentile or greater on the scale sought breast reduction surgery for medically necessary reasons.
Insurance companies would adopt this scale as well, and now it is the standard for determining coverage for breast reduction surgeries. The scale is based on a calculation that the doctor makes of the patient’s overall body surface area compared to the amount of breast tissue to be removed.
The Schnur Sliding Scale*
*Note: There are other considerations as well; for the most accurate estimates, please contact us for a consultation.
As you can see, the Schnur scale tops out at 1,000 grams, or one kilogram, of breast tissue to be removed. Empire Plan breast reduction coverage notes that as well, waiving the requirement for the body surface area calculation if it’s anticipated that more than one kilogram will be removed.
But, what if your doctor is wrong? There is a chance that less breast tissue than anticipated will be removed. Will that cause your insurance to change its position on medical necessity? Luckily, in most cases, insurance will still cover the surgery.
What If the Schnur Scale Calculation Is Wrong?
Many individuals have this concern when they learn about the Schnur scale. They worry that if their plastic surgeon removes less than what was initially calculated, they may have to pay for the surgery out-of-pocket. However, that is not usually the case. The language in the Empire Plan specifically notes the anticipated amount to be removed.
As long as your surgeon makes a good faith estimate that meets the insurance company’s criteria, surgery would still be considered medically necessary. Of course, the key to that is going to a practice that understands both sides of the equation.
Evaluating Your Empire Plan Breast Reduction Coverage
Here, I’ve focused heavily on the Schnur scale, but it’s not the only criteria for medically necessary breast reduction surgery. Even if you have more than a kilogram of breast tissue to be removed, the surgery won’t be covered unless you also have a qualifying condition. The Empire Plan lists these conditions as “cervical or thoracic pain syndrome,” “submammary intertrigo,” or “thoracic outlet syndrome.” Primarily, the medical reason behind breast reduction surgery is pain or a chronic skin condition.
However, it’s up to a doctor to determine if that condition would be improved by breast reduction surgery. The Empire Plan policy also states that the doctor needs to have a reasonable belief that the surgery will resolve the patient’s condition. That can only be done after a thorough physical examination, patient history, and medical records review.
By working with a practice that’s familiar with breast reduction surgeries and Schnur scale breast reduction requirements for insurance coverage, you’ll be better able to understand if you qualify.
Bringing Patient Advocacy to Breast Reduction and Reconstruction
Harris Plastic Surgery can help walk you through Schnur scale breast reduction requirements under your Empire plan policy. To learn more, contact us for a consultation.
Joanne Parrinello, Practice Manager
Joanne Parrinello is an expert patient care coordinator, with two decades of experience navigating the complex financial side of medically necessary breast reduction and reconstruction surgery. She acts as a guide to patients, helping them understand their options and their expected out-of-pocket expense. The insurance industry can be complex and filled with jargon that makes you feel like you need a translator. At Harris Plastic Surgery, Joanne is that translator.