Across Aetna, Cigna, Anthem/Elevance, UnitedHealthcare, and Medicare, the medical-necessity criteria are remarkably consistent. They generally want to see:
The Schnur sliding scale estimates how much breast tissue removal is "reconstructive" rather than cosmetic, based on your height and weight (body surface area). Some insurers use the published Schnur table; others set their own fixed gram minimums. The exact number that applies to you depends on your insurer and your measurements — which is exactly the kind of thing our free check calculates for you.
The most common denial reasons aren't that the surgery wasn't justified — it's that the chart said "chronic pain" instead of documenting duration, failed conservative care, and the expected tissue removal. A file that speaks the insurer's language up front is what turns a likely denial into an approval, and it's what saves months of appeals.
Answer a few plain questions and get a readiness read against your insurer's actual criteria, plus a one-page sheet to bring to your surgeon.
Check my coverageIt depends on your insurer and your body surface area. Many plans use the Schnur scale, which sets a gram-per-breast minimum based on your height and weight; others use a fixed minimum. Falling below the threshold is a common reason a claim is treated as cosmetic.
Medicare can cover it when it's medically necessary and documented — symptoms, failed conservative treatment, and expected tissue removal — rather than for cosmetic reasons.
Typically: a symptom history with duration, evidence of conservative treatments you've tried, photos, and the surgeon's estimate of grams to be removed. Our free check produces a one-page sheet listing exactly what your insurer looks for.
No. Purely cosmetic breast reduction isn't covered. Coverage hinges on documented physical symptoms and meeting the plan's medical-necessity criteria.