Breast Reconstruction - Medicare Advantage (Revised)
Humana·IA, KS, MO, NE, IN, MI, KY, OH, CA, HI, NV, AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY, AR, CO, LA, MS, NM, OK, TX, DE, DC, MD, NJ, PA, AL, GA, TN, NC, SC, VA, WV, FL, PR, VI · Plastic Surgery, General Surgery, Oncology·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 revised its breast reconstruction coverage policy (effective 08/03/2026) to clarify medical necessity criteria for reconstruction procedures following mastectomy, trauma, or congenital abnormalities. The policy applies MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction and establishes criteria for determining coverage of implant removal, reduction mammaplasty, and related procedures. Billing teams must identify the appropriate MAC jurisdiction for each claim and apply the correct LCD requirements.
Action Required
Action needed
Before 08/03/2026: (1) Billing team must map all service locations to their corresponding MAC jurisdiction (J5, J8, J15, JE, JF, JH, JL, JJ, JM, JN) as listed in the policy. (2) For each jurisdiction, download and implement the applicable LCD requirements from the CMS Medicare Coverage Database (reference LCD numbers: L39051, L39506, L35163, L35090, L33428, L38914, and LCA numbers: A58774, A59299, A57221, A56587, A56658, A58573). (3) Update billing system rules to require prior authorization workflows for CPT codes 19328, 19330, 19370, 19371, and 19318 based on MAC-specific medical necessity criteria. (4) Providers must document medical necessity for breast implant removal/revision and reduction mammaplasty claims per LCD L33428 criteria for jurisdictions J6/JK. (5) Train billing and prior authorization staff on jurisdiction-specific LCD requirements. Failure to apply correct MAC-specific criteria will result in claim denials or payment delays.