The short version
- Reduction mammaplasty is CPT 19318. Coverage turns on grams removed per breast versus the payer’s threshold. Run the patient’s number first with our breast reduction calculator.
- One adolescent series put the approval rate at 79.5%. So roughly one in five medically necessary reductions still gets denied.
- Two gates have to clear, not one: the gram minimum and the symptom record. Clear the grams, skip the symptoms, denied anyway. And Robert Schnur said his scale was never meant to gate coverage.
Yes, if you clear two gates
Breast reduction is covered when it’s reconstructive, and reconstructive is defined almost entirely by how much tissue comes out. Clear the payer’s gram threshold per breast and the first gate opens. Miss it and the procedure is cosmetic by default, no matter how symptomatic the patient.
But grams alone don’t pay the claim. Every major policy also wants a documented symptom history. So a 79.5% approval rate is the optimistic read. Flip it and one in five clean cases still bounces, and the most common reason isn’t too little tissue. It’s a surgeon who removed plenty and a record that never tied the symptoms to the breasts. Two gates, every time.
Three ways payers set the bar
There is no national number. Payers pick one of three methods, and they don’t agree. A flat minimum means you clear a fixed gram figure per breast. A BSA-indexed table means the required grams rise with body size. The Schnur scale means anything at or above the 22nd percentile reads as reconstructive and anything below the 5th reads as cosmetic.
Here’s the cruelty in the math. On a BSA-indexed or Schnur payer, the bigger the patient, the more tissue you have to remove to call it medically necessary. The patients with the most symptoms face the highest bar. A 2024 analysis said it plainly: the Schnur scale discriminates by body habitus.
How the major payers actually set it
| Payer | Method | The number |
|---|---|---|
| Aetna | BSA-indexed gram table | Grams scale with BSA; per-breast minimum set by the table |
| Cigna | Schnur scale | ≥ 22nd percentile for BSA, or a flat-gram alternative |
| BCBS (plan-dependent) | Flat minimum | ~500 g per breast common |
| UnitedHealthcare | InterQual | Symptom + gram criteria, no single published gram floor |
Treat the gram target as a pre-op number, not a post-op surprise. On a Schnur or BSA-indexed payer, calculate the required grams from height and weight before the case and confirm the surgical plan clears it. Our breast reduction (Schnur/BSA) calculator runs that math for you. Coding a 19318 and hoping the specimen weight lands above the line is how a clean case turns into an appeal.
Grams don’t pay alone
The second gate is the symptom history, and it’s where documentation does the work. Payers want the pattern. Neck, back, or shoulder pain. Shoulder grooving from straps. Intertrigo in the inframammary fold. And usually a trial of conservative measures (supportive garments, PT, NSAIDs) over a defined period.
The line that survives review attributes the symptoms to the breasts specifically. “Chronic back pain” is a write-off waiting to happen. “Bra-strap grooving with submammary intertrigo unresponsive to three months of conservative care” is the version that pays. Document the failed trial at the visit. Reconstructing it at appeal reads exactly like what it is.
The scale its author rejected
Here’s the nuance that sinks careful claims. The Schnur sliding scale came from a 1991 study estimating average reduction volumes by body size. Schnur himself later challenged carriers for misusing it and said it should no longer be used as coverage criteria. The literature backs him. Schnur is a poor predictor of resection weight, and the Appel method estimates better, especially in younger and higher-BMI patients with larger resections.
None of that stops the payer. So you document to a standard its author disavowed and the evidence undercuts. Don’t relitigate Schnur on the claim. Clear the percentile when the payer uses it, and when you appeal a denial, attack the symptom-necessity link. It stands on firmer ground than a 1991 estimate the field has already moved past.
What to submit for a clean 19318
For a 19318 that clears first pass, the packet carries the estimated and then actual specimen weight per breast, the payer’s threshold and method for that patient’s BSA, the symptom history tied to the breasts, the conservative-treatment trial and its duration, and the pre-op photographs. Bilateral cases document weights per side.
Assemble it as the submission, not the appeal response. First-pass approval costs you one packet. The win on reconsideration costs you three months of days in AR. If the appeals are stacking up faster than your front desk can work them, that volume is what our medical billing operation exists to absorb.
Frequently asked questions
Is breast reduction covered by insurance?
Often, yes, when it’s reconstructive. Coverage turns on removing enough tissue per breast to meet the payer’s gram threshold and documenting a symptom history (back, neck, and shoulder pain, strap grooving, intertrigo) with a failed trial of conservative treatment. One adolescent series found a 79.5% approval rate, so roughly one in five still gets denied.
What is the Schnur sliding scale?
The Schnur scale relates required breast-tissue removal to body surface area by percentile. Several payers, including Cigna, treat removal at or above the 22nd percentile as reconstructive and below the 5th as cosmetic. Its author later said it was never intended as a medical-necessity threshold.
How many grams must be removed for insurance to cover breast reduction?
Generally speaking, the payer’s method sets it. Some use a flat minimum (around 500 g per breast is common), some use a BSA-indexed table where the requirement rises with body size, and some use the Schnur scale’s 22nd percentile. Calculate the patient’s specific number before the case.
What CPT code is used for breast reduction?
CPT 19318 (reduction mammaplasty) is the single code for the procedure. Coverage, not coding, is the hard part. The same 19318 is paid when reconstructive criteria are met and denied when the case reads as cosmetic.
Drowning in reduction-mammaplasty denials?
Plastic surgery coverage fights are what we do, payer by payer. Talk to us about getting the gram math and the symptom packet right before the claim goes out, not at appeal.
This article is for general informational purposes and is not coding, billing, or legal advice. Verify current rules and your contractor policies before making operational decisions.
