Many insurance policies break down breast reduction requirements 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 post will tell you 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, those deemed medically necessary are.
In the past, one of the biggest challenges with breast reduction surgery was determining exactly that—when a procedure qualified as 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.
Several formulas have emerged to determine how much breast tissue must be removed in order to prove medical necessity. Of these, the Schnur sliding scale is the most commonly used in insurance policies. The Schnur sliding scale came from a study by plastic surgeons that compared the amount of breast tissue to be removed with the patient’s body surface area as an objective measure of medical necessity. Specifically, the study revealed that all women who fell into the 22nd percentile or greater on this scale sought breast reduction surgery for medically necessary reasons.
Insurance companies adopted the surgeons’ sliding scale, and now it is the standard by which most policies determine the amount of coverage for breast reduction surgeries. The scale is based on a calculation the doctor makes that compares the patient’s overall body surface area to the amount of breast tissue to be removed.
As you can see, the Schnur scale tops out at 1,000 grams (one kg., or 2.21 lbs.) of breast tissue to be removed. For many insurance plans, the measurement stops there as well, as they often waive the requirement for calculating body surface area if a surgeon anticipates removing more than one kilogram of tissue.
But what if your doctor is wrong? There is always a chance that less breast tissue will be removed than anticipated. 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 patients express the same 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 many insurance plans states the anticipated amount to be removed. To be certain, however, you should consult with an expert care coordinator who can act as a liaison between you and your insurance provider.
As long as your surgeon makes a good faith estimate that meets the insurance company’s criteria, your breast reduction surgery is still considered medically necessary. Of course, the key to avoiding any unnecessary concern is to go to a practice that understands both sides of the equation.
Evaluating Your Breast Reduction Coverage
While I’ve focused heavily on the Schnur scale in this post, 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. Insurance policies commonly list 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.
It’s up to your plastic surgeon to determine if that condition would improve with breast reduction surgery. Many policies also state that the plastic surgeon must 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.
Working with a practice that’s familiar with breast reduction surgeries and Schnur scale requirements for insurance coverage can give you the reassurance of understanding how you qualify. The expert care coordinators at Harris Plastic Surgery make sure you understand all the requirements necessary for your insurance to cover your breast reduction surgery.
Bringing Patient Advocacy to Breast Reduction and Reconstruction
Harris Plastic Surgery can help walk you through Schnur scale breast reduction requirements under your insurance 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.