Deep, sourced explainers on how insurers actually decide what they'll cover — the real 2026 criteria, compared side by side by insurer, digested from each company's own published policy.
The same patient, same diagnosis, same test results — approved by one insurer, denied by another. We compared the actual 2026 criteria across eight procedures and found gaps wide enough to change the outcome: an 8-point BMI gap for a sleep-apnea implant, a 50% difference in breast-reduction thresholds, a three-year age gap for depression treatment.
The AHI and BMI windows that decide it — and why Anthem stops at BMI 32 while Cigna, Aetna and UnitedHealthcare go to 40.
Read the guide →Why it's the X-ray (Kellgren-Lawrence Grade 3–4), not the pain, that decides — plus the conservative-care trial each insurer wants.
Read the guide →The first gate isn't your BMI — it's whether your plan covers anti-obesity drugs at all, and the supervised-program trial that differs by insurer.
Read the guide →There's no fixed number — insurers scale the gram requirement to your body size with the Schnur scale, and Aetna's table is stricter than the rest.
Read the guide →The handful of fixable reasons most prior-auth requests are denied — and how to get ahead of each one.
Read the guide →It's almost always timing and documentation, not the scan — the red-flag fast track versus the conservative-care path.
Read the guide →Skilled need, a plan of care, and functional progress — what keeps therapy covered, and the maintenance trap that ends it.
Read the guide →When it counts as reconstructive rather than cosmetic — symptoms, conservative care, and the tissue threshold.
Read the guide →The guides explain the rules; the free tools check where you stand against your insurer's real criteria in about two minutes — across weight & metabolic, sleep apnea, imaging, orthopedic, therapy, cosmetic, mental health and more.