| What's being decided | The lenient end | The strict end | Why it matters |
|---|---|---|---|
| Inspire implant — BMI ceiling | Cigna / Aetna / UHC: up to 40 | Anthem: 32 · Medicare: under 35 | An 8-point BMI gap flips the answer for a large share of candidates |
| Inspire implant — AHI ceiling | Cigna / Aetna / UHC: up to 100 | Anthem / Medicare: 65 | Severe-apnea patients qualify under some insurers, not others |
| GLP-1 weight-loss drug — prior program | Cigna: 3 months | Aetna / Anthem: 6 months | Doubles the wait before the drug can even be requested |
| Breast reduction — tissue threshold | Cigna / Anthem (Schnur-22) | Aetna (~50% more grams at the same body size) | Same surgery, "enough" under one insurer and "not enough" under another |
| TMS for depression — minimum age | Aetna / Cigna: 15 | Most others: 18 | Adolescents qualify under some insurers and not others |
| TMS for depression — required add-on | Cigna: a psychotherapy trial | Aetna: an augmentation medication | You can do everything Cigna wants and still miss Aetna's bar |
| Blepharoplasty — visual-field loss | Aetna: 12° | Most others: 20° | Nearly double the impairment required for the same eyelid surgery |
| Septoplasty — medical-management trial | Aetna: 4 weeks | Cigna: 6 weeks | A different wait before nasal surgery is approved |
Inspire is an implant for people who can't tolerate a CPAP machine. Every insurer covers it — after CPAP fails, within an AHI and BMI window. But the BMI ceiling ranges from 32 at Anthem to 40 at Cigna, Aetna, and UnitedHealthcare, with Medicare just under 35. A patient with a BMI of 37 and severe sleep apnea is a straightforward approval at three insurers and a flat denial at two others — same airway, same failed CPAP, same DISE. The clinical evidence didn't change between insurers; only the line in the policy did.
Insurers don't use a fixed gram number for breast reduction. They use the Schnur scale, which sets the required tissue removal based on your body size. That's reasonable on its own — but the insurers don't use the same scale. Aetna's table requires meaningfully more tissue than Cigna's or Anthem's at the identical body size: around 855 grams per breast where Cigna would want about 575, for someone 5'7" and 180 lb. Add that Aetna also wants two documented symptoms instead of one and a full year of symptom history, and the same person can be an easy approval under one insurer and a denied appeal under another.
TMS (transcranial magnetic stimulation) for depression shows the pattern at its sharpest. Aetna and Cigna cover it from age 15; many other plans start at 18 — so an adolescent qualifies or doesn't depending purely on the insurer. And the required "you've tried enough first" step is different in kind: Cigna wants a documented course of psychotherapy; Aetna wants an augmentation medication. A patient who completed everything Cigna's policy asks for can be denied by Aetna for missing a step that was never on Cigna's list.
Two structural reasons. First, each insurer writes its own criteria, or licenses them from a benefit manager (Cigna and Aetna lean on eviCore; Anthem on Carelon), and those organizations draw the evidence into slightly different rules. Second — and this is the part that should bother patients most — UnitedHealthcare delegates much of its surgical and procedural decision-making to a proprietary rule set called InterQual, which is licensed behind a login and not published. So for a range of UHC procedures, even the criteria themselves aren't visible to the patient or the ordering doctor in advance. (Owned, as it happens, by Optum — UnitedHealth's own parent.)
The net effect is an information gap that runs entirely in the insurer's favor. You're asked to meet a bar you can't see, set in a place that differs from the insurer down the street, and you only find out where the bar was after you've been denied.
Pick your procedure and your insurer, and see exactly where you stand against that insurer's real 2026 criteria — plus what to document if you're not there yet.
See where you standYes, and the differences are often large. For the same procedure and the same clinical situation, insurers frequently set different thresholds — a different BMI ceiling, a different waiting period, a different amount of impairment, or a different required step before approval. We found gaps as wide as 8 BMI points for the Inspire implant and a roughly 50% difference in the tissue a breast reduction must remove, purely between insurers.
Because each insurer publishes its own medical policy with its own thresholds, and they don't match. A request that clears one insurer's bar can fall short of another's stricter requirement — a longer prior-treatment trial, a higher impairment threshold, or a step the first insurer didn't require. The clinical facts didn't change; the policy did.
Yes. Under the Affordable Care Act and ERISA, when your claim or prior authorization is denied you have the right to request the specific clinical criteria the insurer applied — the policy name, version, and the exact criteria you didn't meet. For insurers that use a proprietary system like InterQual, you can specifically request the InterQual criteria used in your case.
It depends on the procedure — no single insurer is strictest across the board. Aetna is notably strict on several reconstructive procedures (breast reduction, blepharoplasty). Anthem and Medicare are strictest on the Inspire sleep-apnea implant. Anthem requires the most documentation for GLP-1 weight-loss drugs. The only reliable answer is to check the specific insurer for the specific procedure.
These figures are digested from each insurer's published 2026 policies and were last verified in June 2026. Coverage criteria change over time and can vary by individual plan, so always confirm against your own plan documents before relying on any single figure.
Go deeper: Inspire coverage by insurer · Knee replacement by insurer · GLP-1 coverage by insurer · Breast reduction grams by insurer · all coverage tools