Humana·IL, MN, WI, CT, MA, ME, NH, NY, RI, VT, KY, OH, CA, HI, NV, AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY · Radiology, Oncology, General Practice +2 more·Medicare Advantage
Effective date
Jul 1, 2026
We identified it
Jun 30, 2026
Days to comply
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Summary
This is a revised Medicare Advantage policy for breast imaging (effective 07/01/2026) that establishes coverage criteria for mammography, digital breast tomosynthesis, breast MRI, and ultrasound. The policy clarifies medical necessity requirements and references applicable Local Coverage Determinations (LCDs) by MAC jurisdiction. Billing teams must verify which MAC jurisdiction applies to their geographic location to determine specific coverage rules.
Action Required
Action needed
By 06/01/2026: Billing team must review and update system edits based on applicable MAC jurisdiction. (1) Identify which MAC jurisdiction(s) serve your practice locations: J5/J8, J6/JK, JE/JF, JH/JL, JJ/JM, or JN for mammography/DBT/MRI; or J15 for KY/OH; or review state-specific MACs listed in policy table. (2) For screening breast MRI (codes 77046-77049, C8903, C8905, C8906, C8908), implement require documentation of: pathogenic/likely pathogenic genetic variants (ATM, CDH1, CHEK2, PALB2, STK11, BARD1, RAD51C, RAD51D, BRCA1, BRCA2, NF1, PTEN, TP53) with age-specific start dates; untested status with first-degree relative carrier status; lifetime risk ≥20% from validated tools (BRCAPRO, BOADICEA/CanRisk, Tyrer-Cuzick); first/second-degree relative with male breast cancer; or prior chest radiation ages 10-30. (3) For diagnostic mammography/DBT (77065-77067, 77061-77063, G0279), apply LCD L33950 criteria if in J15 (KY/OH) jurisdiction, or LCD L33585 criteria for other jurisdictions without LCD. (4) Update billing software, prior authorization templates, and provider education materials to reflect these requirements. (5) Train front-desk and authorization staff on new genetic and risk assessment documentation needs. Failure to comply will result in claim denials for lack of medical necessity documentation.