Breast Excision and Mastectomy - Medicare Advantage (Revised)
Humana·IA, KS, MO, NE, IN, MI, KY, OH, CA, HI, NV, AS, GU, MP, AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY, AR, CO, LA, MS, NM, OK, TX, DE, DC, MD, NJ, PA, FL, PR, VI · General Surgery, Plastic Surgery, Oncology +1 more·Medicare Advantage
Effective date
Aug 3, 2026
We identified it
Jul 30, 2026
Days to comply
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Summary
Humana Medicare Advantage has updated its Breast Excision and Mastectomy policy (HUM-1254-009) effective 08/03/2026. This revised policy clarifies coverage criteria for breast lesion excisions (CPT 19120, 19125), partial mastectomies (CPT 19301, 19302), and gynecomastia mastectomy (CPT 19300) across multiple MAC jurisdictions. The policy establishes specific medical necessity criteria based on biopsy results, lesion characteristics, and anatomical considerations, and applies jurisdiction-specific Local Coverage Determinations (LCDs) for Medicare Administrative Contractors.
Action Required
Action needed
By August 3, 2026: Billing team must update coding and prior authorization workflows to align with revised medical necessity criteria for breast procedures. Specifically: (1) For CPT 19120/19125 (breast lesion excision): implement documentation requirements to capture biopsy findings (atypical hyperplasia, LCIS, phyllodes tumor, fibroadenoma characteristics, intraductal papilloma, radial scar, nipple discharge status) or anatomical contraindications to biopsy; (2) For CPT 19301/19302 (partial mastectomy): ensure documentation includes biopsy-proven malignancy status (DCIS, Stage I-II cancer); (3) For CPT 19300 (gynecomastia mastectomy): apply LCD L39051 criteria for jurisdictions J6/JK/JJ/JM, or applicable MAC LCD for other jurisdictions. Billing team must map submitted claims to correct MAC jurisdiction (J5, J8, J15, JE, JF, JH, JL, JN) and apply corresponding LCD. Update encoder software and claim submission rules to reflect MAC-specific LCD requirements. Providers must document all pertinent clinical findings on operative reports. Failure to align with jurisdiction-specific LCD requirements will result in claim denials.