Schnur Sliding Scale: Expert Discussion Regarding Schnur Scale and Breast Reduction Los Angeles
Breast reduction is among the most popular plastic surgery procedures in the United States. Plastic surgeons recommend breast reduction for a condition known as macromastia. Hormonal, developmental, and age-related changes may cause the female breasts to become excessively large and pendulous. In some patients, this problem may lead to symptomatic changes in the body. Back and neck pain, shoulder grooving with discomfort, frequent moisture-related changes in the skin of the breast fold, and brachial plexus paresthesias are not uncommon in women with large breasts.
Los Angeles Plastic Surgeon Dr. Raffy Karamanoukian
Dr. Raffy Karamanoukian performs breast reduction surgery in Los Angeles in an outpatient surgical center. Patients who have excessively large and pend express may benefit from the cosmetic and medical benefits of a reduction mammoplasty. for those patients who have symptoms related to macromastia, a breast reduction made warrant a medical necessity claim with insurance. Our dedicated plastic surgery staff can help obtain insurance authorization when symptoms of macromastia your quality of life.
PPO Insurance and Breast Reduction
Every PPO insurance company has strict policy standards for a breast reduction when documenting medical necessity. We find that many women 50s strict criteria because they have symptoms that are directly associated with excessively large and pendulous breasts. Large scale breast reductions have tremendous benefits on quality of life. Breast reduction is beneficial for patients who are suffering with back and neck pain, physical discomfort, and skin changes that are directly caused by macromastia.
In your preoperative evaluation, Dr. Karamanoukian well examine your breasts and review your symptoms associated with macromastia. Many of these lifestyle changes are patterned and reproducible as the pendulous breast often put physical strain on the neck and back, as well as the shoulders and upper arms. Historically, insurance companies and plastic surgery associations have tried to establish a metric for successful breast reduction when medical necessity becomes an issue. The Schnur Sliding Scale was developed by a plastic surgeon who identified mathematical predictors of breast reduction benefits, as they relate to the amount of tissue removed during surgery. Based on body surface area, the Schnur Sliding Scale provided a guideline for plastic surgeons and insurance providers for the minimum amount of tissue that was to be removed from patient before it was considered a medically-necessary procedure. The longterm validity of the Schnur Sliding Scale has been invalidated based on an analysis of the data used to create the Schnur Sliding Scale.
The Schnur Sliding Scale is based on your Body Surface Area. If you would like access to a BSA calculator,
click here:
How should the Schnur Sliding Scale be used?
Based on modern standards for plastic surgery, the Schnur Sliding Scale provides a surgeon with basic guidelines for the amount of tissue that they anticipate removing from each breast. Insurance companies and clinical providers have tempered the validity of the Schnur Sliding Scale in determining medical eligibility for insurance coverage. Instead, most plastic surgeons will base their observations on the severity of symptoms associated with macromastia - rather than the size of the breasts.
In our Santa Monica plastic surgery practice, we use current data derived from peer-reviewed publications to establish protocols for reconstructive and cosmetic plastic surgery. The Schnur Scale is merely one of many factor we use to determine if a patient is a suitable candidate for a cosmetic or medical breast reduction. Once a BSA over 2.5 is measured, the Schnur Sliding Scale becomes an inaccurate assessment tool as a pre-operative predictor.
American Society of Plastic Surgeons Opinion on Shnur Sliding Scale
In a public statement issued by the ASPS in 2011 on Reduction Mammaplasty (ASPS Recommended Insurance Coverage Criteria for Third-Party Payers), the authors suggested that the justification for reduction mammaplasty should be based on the relief of clinical signs and symptoms of symptomatic breast hypertrophy. This opinion has much validity, as it presumed that clinicians and insurance payors should be more concerned about symptom-relief as opposed to a mathematical metric based on the Schnur Scale.
The statement defined symptomatic breast hypertrophy as a syndrome of "persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused bx heavy breasts caused by an increase in the volume and weight of breast tissue beyond normal proportions.”
Is the Schnur Sliding Scale for Breast Reduction Valid?
Citing published studies, the ASPS further questions the interpretation of the Schnur Sliding Scale with the following statement: "This survey study design, based on surveyed perception of others, is susceptible to significant bias and does not meet the inclusion criteria for being a moderate or high quality study on the ASPS Level of Evidence Rating Scale (see below). Schnur himself has even challenged insurance carriers’ misuse of the scale and has indicated that the scale should no longer be used as criteria for insurance coverage.”
Finally, the letter concludes with the following discussion on the Schnur Sliding Scale and the Sietchik Formula with the statement: "Based on the limited study findings, Seitchik offered his own formula based on personal recommendation, not scientific data. Since the Schnur sliding scale and Seitchik formula lack scientific rigor and validity, they should not be used as criteria for approval of insurance coverage.”
As guidance, the ASPS public proclamation made the following assertions about obtaining breast reduction coverage as medical necessity. These conclusions are adaptable to patient symptoms and specific presentations, but can be used in total, or individually to ascertain medical necessity.
What Qualifies for Medical Necessity in Breast Reduction
Documentation: Physicians should document the severity of the symptoms of breast hypertrophy (lCD-b-CM: N62) and impact on health related quality of life as measured by a breast specific questionnaire which includes at least two of the following signs/symptoms: • Chronic breast pain (lCD-iD-CM: N64.4) due to weight of the breasts • lntertrigo (lCD-b-CM: L30.4) unresponsive to medical management • Upper back, neck, and shoulder pain (lCD-b-CM: M54.6, M54.2, M53.82, M25.511 —M25.519) • Backache, unspecified (lCD-iD-CM: M54.89, M54.96) • Thoracic kyphosis, acquired (lCD-b-CM: M40.04, M40.14, M40.204, M40.294) • Shoulder grooving from bra straps (lCD-b-CM: M954) • Upper extremity paresthesia (lCD-b-CM: R20.0-R20.9 )due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area • Headache (lCD-iD-CM: R51) • Congenital breast deformity (lCD-ic-CM: 038.0-038.8)
The validity of the Schnur Sliding Scale should take into account patient-specific symptoms and cannot be used singly as a measure of surgery pre-authorization review. Some clinicians would argue that the Schnur Sliding Scale for Breast Reduction has some incremental historical merit.
See reference: "Approved by the Executive Committee of the American Society of Plastic Surgeons®, May 2011 JCD-I0-CM Coding Updated January 2016” on the ASPS website.
Aetna Insurance Medical Pre-authorization for Breast Reduction
Breast Reduction in Los Angeles: Review of Medical Necessity with PPO Aetna Insurance
Review of Aetna Health Insurance Scope of Policy regarding Breast reduction and medical necessity outlines The clinical policy bulletin for reduction mammaplasty. Medical necessity is met based on specific symptom based metrics for macromastia, patient specific measures and clinical history regarding conservative care and therapy documentation, and a stipulation that women over 50 have a negative mammogram for cancer within the two years prior. Interestingly, the following statement on the quantity of breast tissue removal is as follows: "The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using the Mosteller formula.”
"The Aetna guidelines make the following statements on the Schnur Sliding Scale in their policy report: Schnur et al (1991) reported on a sliding scale assigns a weight of breast tissue to be removed based on body weight and surface area. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Each surgeon who participated in the study reported on the height, weight, and volume of reduction of their last 15 to 20 patients, and each surgeon provided their “intuitive sense” regarding the motivation of each patient for breast reduction surgery. Schnur subsequently refuted the validity of the Schnur sliding scale and stated that the scale should no longer be used as a criterion for the determination of insurance coverage for breast reduction surgery (Nguyen et al, 1999)."
"Some individuals, however, have argued that reduction mammoplasty may be indicated in any woman who suffers from back and shoulder pain, regardless of how small her breasts are or how little tissue is to be removed (ASPS, 2002). They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). These studies did not find a relationship between breast weight or amount of breast tissue removed and the likelihood of response or magnitude of relief of pain after reduction mammoplasty."
"It is not intuitively obvious, however, that breast weight would substantially contribute to back, neck and shoulder pain in women with normal or small breasts. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain."
Schnur Sliding Scale for Breast Reduction:
BSA: Refers to Body Surface Area
Weight: Tissue in grams removed from each breast to be considered medically-necessary (not validated in current practice)
(BSA (in m2) = [height (cm)] 0.718 X [weight (kg)] 0.427 X .007449)
| BSA (m2) |
Weight (grams) |
| 1.40 |
324 |
| 1.41 |
330 |
| 1.42 |
335 |
| 1.43 |
340 |
| 1.44 |
350 |
| 1.45 |
355 |
| 1.46 |
360 |
| 1.47 |
365 |
| 1.48 |
375 |
| 1.49 |
380 |
| 1.50 |
385 |
| 1.51 |
395 |
| 1.52 |
400 |
| 1.53 |
405 |
| 1.54 |
415 |
| 1.55 |
420 |
| 1.56 |
430 |
| 1.57 |
435 |
| 1.58 |
445 |
| 1.59 |
455 |
| 1.60 |
460 |
| 1.61 |
470 |
| 1.62 |
480 |
| 1.63 |
485 |
| 1.64 |
495 |
| 1.65 |
505 |
| 1.66 |
510 |
| 1.67 |
520 |
| 1.68 |
530 |
| 1.69 |
540 |
| 1.70 |
550 |
| 1.71 |
560 |
| 1.72 |
570 |
| 1.73 |
580 |
| 1.74 |
590 |
| 1.75 |
600 |
| 1.76 |
610 |
| 1.77 |
620 |
| 1.78 |
635 |
| 1.79 |
645 |
| 1.80 |
655 |
| 1.81 |
665 |
| 1.82 |
680 |
| 1.83 |
690 |
| 1.84 |
705 |
| 1.85 |
715 |
| 1.86 |
730 |
| 1.87 |
740 |
| 1.88 |
755 |
| 1.89 |
770 |
| 1.90 |
780 |
| 1.91 |
795 |
| 1.92 |
810 |
| 1.93 |
825 |
| 1.94 |
840 |
| 1.95 |
855 |
| 1.96 |
870 |
| 1.97 |
885 |
| 1.98 |
900 |
| 1.99 |
915 |
| 2.00 |
935 |
| 2.01 |
950 |
| 2.02 |
965 |
| 2.03 |
985 |
| 2.04 |
1000 |
| 2.05 |
1000 |
| 2.06 |
1000 |
| 2.07 |
1000 |
| 2.08 |
1000 |
| 2.09 |
1000 |
| 2.10 |
1000 |
| 2.11 |
1000 |
| 2.12 |
1000 |
| 2.13 |
1000 |
| 2.14 |
1000 |
| 2.15 |
1000 |
| 2.16 |
1000 |
| 2.17 |
1000 |
| 2.18 |
1000 |
| 2.19 |
1000 |
| |
|