Breast Resection Weight Prediction and Insurance Reimbursement in Reduction Mammaplasty: Which Scale Is Reliable?

Abstract

Background: Many insurance companies in the United States rely on the Schnur sliding scale to predict resection weights to determine medical necessity for breast reduction surgery. Accurate methods to predict resection weights are needed to avoid insurance denials. The authors compared the accuracy of formulas such as the Schnur, Appel, Descamps, and Galveston scales in predicting resection weights, and assessed whether they influence insurance coverage decision. Methods: A retrospective review of bilateral reduction mammaplasty procedures from June of 2017 to June of 2019 was performed at the Mayo Clinic, Rochester. Oncoplastic reduction operations were excluded. The accuracy of each formula-based estimate was evaluated with linear regression analysis. Results: One hundred fifty-four patients (308 breasts) were reviewed. The Schnur scale had low correlation with actual resection weight (r2 = 0.381; b1 = 1.153; p < 0.001). The Appel scale was the most accurate (r2 = 0.642; b1 = 1.01; p < 0.001), followed by the Descamps (r2 = 0.572, b1 = 0.934, p < 0.001) and Galveston (r2 = 0.672; b1 = 0.654; p < 0.001) scales. The Appel, Descamps, and Galveston scales were more accurate for resection weights of 500 g or greater, body mass index greater than 30 kg/m², and patients younger than 50 years. For resection weights of 500 g or greater, the median difference between the estimated and actual resection weight for the Schnur, Appel, Descamps, and Galveston scales was −211.4 ± 272.3, −17.5 ± 272.3, −9.6 ± 229.5, and −99.2 ± 238.5 g, respectively. No scale was accurate for resection weights less than 500 g. Insurance reimbursement was denied in 15.56 percent of patients; of these, 23 percent had resection weights less than 500 g. The Schnur scale overestimated the resection weights in 28.9 percent of patients. Conclusions: The Schnur scale is a poor predictor of breast resection weight. The Appel scale is the most accurate estimator, especially in the young and obese population with larger resections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

So Long, Schnur Scale

“…1 Within this context, plastic and reconstructive surgery represents a sizeable portion of the unmet surgical need in LMICs, accounting for approximately 16% of all surgically treatable conditions. 2 To address this challenge, a comprehensive and multifaceted approach is required.…”

“…5 Insurers prefer quantitative criteria and therefore continue using the Schnur scale despite mounting evidence denouncing its relevance, as well as the existence of more reliable resection weight calculations. 2,6 Numerous studies have demonstrated that resection weights smaller than Schnur's 22nd percentile or the arbitrary 500-g weight minimum set by some insurers substantially relieve macromastia-related symptoms. 8 There is no significant difference in symptom relief across all resection weights and body mass index values.…”

“…Copyright ©2012 by the American Society of Plastic Surgeons W orldwide, nearly 5 billion people lack access to basic surgical services. [1][2][3] In low-and middleincome countries (LMICs), access is critically constrained, with only 3.5% of all surgical procedures being provided to 34.8% of the world's population. 1 Within this context, plastic and reconstructive surgery represents a sizeable portion of the unmet surgical need in LMICs, accounting for approximately 16% of all surgically treatable conditions.…”

“…Furthermore, the high prevalence of facial clefts in LMICs has significant implications for quality of life and can be effectively addressed through plastic surgery interventions. 2 The pioneering organization Interplast, now ReSurge, laid the foundation for providing free reconstructive surgery in LMICs when it was established in 1969. 4 Inspired by this initiative, various additional organizations, such as Smile Train and Operation Smile, have adopted a similar model, where volunteer surgeons travel to LMICs and dedicate several weeks to providing surgery for as many patients as possible before returning to their home countries.…”

Bilateral gigantomastia due to benign breast tumors: a case series and brief review focusing on bilateral diffuse pseudoangiomatous stromal hyperplasia

“…In the United States, insurance providers employ assessment tools, such as the Schnur scale, to determine the minimum breast resection weights that justify the medical need for reduction surgery. Typically, insurance companies will cover this procedure if the amount of tissue to be removed exceeds the 78th percentile based on the individual's body surface area or weighs more than 500 g [4].…”