Aetna's Itty Bitty Titty Committee

When insurance companies decide how much breast you can keep

Photo: Getty.

Breasts. Now that I have your attention: Breasts. Yes, we are talking breasts today. Get your giggling out of the way now, because this really is an example of American healthcare injustice.

Insurance companies want to avoid paying for anything they can feasibly and legally(ish) get out of paying for. They employ a number of strategies for this, like step therapy requirements and prior authorizations. Sometimes they just Do Not, and it ends up being your job to nudge and pester them until they Do. This desire has also led them to develop a strict doctrine about which things are not ‘medical’ care, like dentistry, hearing aids, and glasses—you know, since your teeth, ears, and eyes are not part of your body. And then there are things that they do cover, but only under very strict and limited circumstances, with as many hurdles to cross as they can throw up. This is how insurance tends to approach breast reduction surgery, as Lisa found. (I’ve changed her name at her request).

Lisa is a mom in Texas. Last year, a routine mammogram uncovered a benign cyst. She had been thinking about breast reduction surgery for a long time, since she’s always had “larger breasts for her frame,” she said, and it causes pain and tension in her back, neck, and shoulders. This is a common symptom of breast hypertrophy, the medical term for having large breasts, along with “headache, aching shoulders, painful shoulder grooves, low back pain, intertrigo of the inframammary crease, mastalgia [breast pain], poor posture, difficulty exercising, and difficulty working a job without absenteeism.”

The mammogram inspired Lisa to act. She saw a plastic surgeon—one who takes insurance—and told them she wanted to go down to a C cup. The average bra size in the United States is a 34DD, which is two cups bigger than a C, though finding the right size is tough. This seemed reasonable to her and her doctor.

But not to Aetna, her insurance company. Her doctor’s first prior authorization request was denied. Aetna would only approve the surgery if they removed more tissue—down to a B cup, her doctor said. This “didn’t make sense” to Lisa. What made even less sense is that her doctor said Aetna would approve the claim at a C cup if she lost weight; that is, if she weighed less, she’d be allowed to keep more breast tissue. “Why would it make more sense that I could get what I wanted if I lost weight,” she wondered: “Wouldn't I be more disproportionate then?” She said the last time she was a C cup was in college, when she was “super thin, like 110lbs,” and added: “There is literally no way for me naturally to get to a C cup unless I had some sort of wasting disease.”

This baffling requirement stems from the charts that insurance companies use to determine whether a breast reduction is medically necessary, which are often based on a method called the Schnur Sliding Scale.

The Schnur scale was created by Dr. Paul Schnur in 1991, as an attempt to set a standard for distinguishing between cosmetic and reconstructive breast reduction. It uses the patient’s body surface area, calculated using their body mass index (BMI), to set a minimum weight of breast tissue removed for a surgery to be considered medically necessary. The scale itself is far from perfect: A 2002 study in Medical Decision Making, co-authored by Schnur himself, found that patients who met the Schnur cutoff level did not score better on a scale of symptom improvement than those who didn’t meet it. In that study, the authors noted that the scale was originally “based on subjective physician recall and opinion, not on hard data,” and proposed instead that “the definition of medical necessity for the health burden of breast hypertrophy [should] be based on a woman’s report of her symptoms using a structured, validated questionnaire.”

Dr. Linda Phillips is the chief & program director of plastic surgery at the University of Texas Medical Branch in Galveston, Texas, and the president of the American Association of Plastic Surgeons. In an interview, Phillips said the Schnur scale is “not accurate for everybody,” but is still “commonly adopted by insurance companies in order to be a standard.” Insurance companies use the scale ostensibly to ensure that they aren’t covering any procedures that are being sought for aesthetic purposes, by weeding out people who only want a small amount removed. Sometimes, insurance companies will require a minimum weight of 500g per breast, regardless of the size of the individual in question. Still, Phillips said she has “patients who, at a D cup, are having this problem with recurrent neck, back, shoulder pain, and then when they get even a small reduction, it's just enough to put them under and they're very happy then with the results.” Many plastic surgeons choose not to take insurance at all—meaning patients must pay out-of-pocket for the procedure—in part, Phillips said, because of the “hoops” they have to jump through (though she noted that others simply find there’s more money to be made by focusing on aesthetic procedures).

Phillips also said Aetna is “one of the more aggressive” insurance companies when it comes to denying breast reduction procedures. This is reflected in the scale they use, available on their website, which is much more restrictive than the Schnur scale. For example, at a body surface area of 1.5m², Aetna requires a minimum weight of 385 grams removed from each breast, whereas the Schnur scale would only require 260g. (This refers to actual breast tissue only; any fatty tissue removed doesn’t count.) At a body surface area of 2m²—roughly the body surface area of a person weighing 200lbs with a height of 5’3'—the Schnur scale would require 628g removed per breast, compared to 935g under Aetna’s rules.

(Aetna did not respond to repeated requests for comment about why their scale is more aggressive than the Schnur scale or other insurers’ scales, or why they denied Lisa’s request—apart from an initial reply telling me that Lisa needed to submit a HIPAA release form to allow them to speak to me about it, which she had already done. When I told them she had faxed it in days before & sent them a copy of her form myself, I received no further replies. Lisa also received an email from an Aetna representative reaching out about her prior authorization request, which specifically mentioned the email I had sent Aetna.)

This isn’t to say that other insurers aren’t strict about covering these procedures. A Blue Cross of North Carolina policy document from 2017, for example, requires that all patients seeking breast reduction with a BMI over 27 and who experience lower back pain undergo “a documented and legitimate medically based attempt to reduce and maintain weight.” This must involve “regular visits with a practitioner, nutritionist, or other recognized weight loss program over 3 months,” plus “reasonable dietary modifications and appropriate aerobic exercise.” (Wot, no lifting?) But at least Blue Cross used the unmodified Schnur scale. So does Cigna, in a 2021 policy brief.

Phillips noted that patients are often required to try other things in addition to weight loss, like topical prescription therapy for chafing caused by large breasts. Some “go to pretty extreme lengths” to keep the area dry to avoid the “obnoxious odor” of the topical treatments, she said. A few of her patients have been referred over from surgeons who they had seen for neck pain, and some even “had cervical spine fusions, and because it didn't solve the problem, were referred over for breast reductions as well.”

Lisa’s plan didn’t specifically require her to lose weight as a solution in itself, but it was suggested by her doctor as a way to get Aetna to cover the surgery at the lower amount of tissue she wanted removed. So she embarked on a plan to lose weight—something she said she had wanted to do anyway, for herself. She and her doctor hoped if she lost a little bit of weight, and also agreed to have slightly more breast tissue removed, that Aetna might approve it.

After Lisa’s months of efforts to lose weight, including working with a trainer at the gym, she told me she lost 15lbs—less than the amount her doctor said she’d need to lose, but still a huge success. She was optimistic that the surgery would be approved.

But it wasn’t. The second request was denied, despite working towards the guidelines she had been given last year. She put together an appeal herself, with testimony from her personal trainer and her OB-GYN. Her doctor did a “peer-to-peer” review with a doctor at the insurance company, a process that is frequently frustrating: Often, the insurance company’s doctor won’t be trained in the specialty in question at all. In an American Medical Association survey of physicians, only 15 percent reported that the health plan’s doctor “always” or “often” has the “appropriate qualifications” to asses the request. After meeting with her doctor again, Lisa agreed to lose more breast tissue than she had initially wanted to.

Lisa’s only other option would be changing her insurance provider. She’s currently on her husband’s plan through his job, which has very low cost-sharing. She could switch to the plan she gets through her part-time job during the next open enrollment period, to see if they would cover her surgery—but that plan has higher out-of-pocket costs. Even if she switches, there’s no guarantee the new company would pay for it either. She might end up paying more for a plan that doesn’t cover what she needs anyway.

The 2011 American Society of Plastic Surgeons’ Evidence Based Clinical Practice Guideline recommended that “individual symptomatology” is a more accurate predictor of relief from surgery than the weight of breast tissue, citing data from the “BRAVO” study, which found that the amount removed wasn’t an accurate predictor of symptom relief. Aetna disagrees. Its clinical policy bulletin on breast reductions describes these studies as “poorly controlled,” and suggests that “the lack of an expected ‘dose-response’ relationship between the amount of breast tissue removed and the magnitude of symptomatic relief in these studies raises questions about the validity of these studies and the effectiveness of breast reduction as a method of relieving shoulder and back pain.” By this, they mean it just makes sense that patients would experience more symptom relief from having more breast tissue removed, whatever ‘doctors’ report. The implication is that plastic surgeons can’t be trusted to determine medical necessity by themselves.

Even if Aetna was right about these studies, where would that leave patients? They sure as hell can’t trust their insurance company to be fair about these guidelines, since they have such a strong financial incentive not to cover anything they can get away with not covering, particularly something where patients might be primed not to expect coverage. But plastic surgeons are also financially motivated to perform surgeries (also true of cardiologists, and many other specialties in American medicine). The fee-for-service model, which is by far the most common payment system in American healthcare, incentivizes doctors to order more tests, more surgeries, more procedures, at higher costs. It’s vital for patients to be able to trust that their doctor’s recommendations, particularly for surgical procedures that carry risk of complications, aren’t influenced by the profit motive, something that is always a challenge in American healthcare. The process of finding a doctor you trust can be very difficult. It’s a combination of location, wealth, insurance networks, time available to shop around, and pure luck.

But let’s be real: The relationship between a patient and a doctor is infinitely more likely to be based on facts, trust, and the foundational principles of medicine than the one between a patient and their insurance provider. Insurance companies aren’t trying to protect patients from greedy doctors out of the kindness of their hearts; at least some doctors went to medical school to help patients, a goal that’s not anywhere in the agenda of insurance companies.

In Lisa’s case, it’s not like some grifting plastic surgeon is forcing a procedure on her that she doesn’t need. She’s had pain for years, and she knows the risks. She was willing to compromise, and get more tissue taken out than she initially wanted, to have a bigger physical and aesthetic change made to her own human body as a result of an insurance company’s requirement. After months of effort to lose weight, back-and-forth with her insurance and her doctors, and simply waiting and delays, her doctors have settled on what she described as “a B+/C- cup situation.” All of this happened not because of a doctor’s recommendation, but because an insurance company has a chart mandating how much titty a patient can keep. What a country.