CPT 19303, in plain terms, covers Simple mastectomy taking all breast tissue on one side while leaving the chest muscle and underarm lymph nodes intact, reported per side. CPT 19303 is referenced in 17 tracked payer policy changes from EmblemHealth, Healthfirst, and 6 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 19303 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 19303 on AAPC
Effective April 1, 2026, New York Medicaid and HARP will only cover breast cancer surgery (mastectomy and lumpectomy) at high-volume facilities performing 30+ procedures annually. Claims and preauthorization requests from low-volume facilities will be denied. Patients must be directed to high-volume providers. Diagnostic/excisional biopsies and post-surgical care remain unrestricted.
Healthfirst's NYS Medicaid Breast Cancer Selective Program policy (PO-RE-168v1) requires prior authorization for all breast cancer surgical procedures under the program, and those procedures must be performed at NYS-approved facilities. Services rendered at restricted facilities are not eligible for reimbursement, and authorization requests listing a restricted facility will be denied. The policy applies only when a qualifying diagnosis code from Appendix A is linked to a qualifying procedure code, and Appendix A states the Medicaid breast cancer service exclusion is effective April 1, 2025.
Independence Blue Cross updated MA11.077j to add three new ICD-10 diagnosis codes effective 10/01/2026: QA1.790 (Familial cancer syndrome with pathogenic BRCA1 mutation), QA1.791 (Familial cancer syndrome with pathogenic BRCA2 mutation), and QA1.792 (Li Fraumeni syndrome). These codes now qualify for coverage of prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy procedures under Medicare Advantage plans.
Independence Blue Cross updated policy 11.08.19t with three new ICD-10 diagnosis codes effective 10/01/2026 to support coverage determinations for prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy in patients with familial cancer syndromes. The billing team must ensure these new codes (QA1.790, QA1.791, QA1.792) are recognized in billing systems and attached to claims for these procedures when applicable.
Risk-reducing mastectomy may be considered medically necessary for individuals at high risk of breast cancer, including those with lobular carcinoma in situ, a known BRCA1 or BRCA2 variant, another high-risk gene variant such as TP53, PTEN, CDH1, STK11 or PALB2, or chest radiotherapy before 30 years of age. It is considered investigational for all other indications, including contralateral risk-reducing mastectomy in individuals with breast cancer who do not meet high-risk criteria. On 10/01/2026 the code reference was updated to add ICD-10 diagnosis codes QA1.790, QA1.791 and QA1.792.
Policy 7.01.84 sets the criteria for gender affirming surgery and treatments for commercial and Medicare Advantage members, with a current effective date of May 21, 2026. Gender affirming surgery may be considered medically necessary when the member has reached age 18 (except for mastectomy), one letter from a qualified professional documents gender dysphoria that is marked and sustained for at least 6 months, and the other general criteria are met. Breast augmentation, hysterectomy, gonadectomy and genital reconstructive surgery each require six months of continuous hormone therapy or a documented contraindication to hormone therapy, and voice modification and voice therapy require review by a Health Plan Behavioral Health Medical Director.
Independence Blue Cross updated MA11.077i to MA11.077j, adding nine new ICD-10 diagnosis codes effective 10/01/2025 to support coding for prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy procedures. The policy itself was reissued on 04/01/2026 to reaffirm the Company's continuing coverage position; no changes to medical necessity criteria or procedure coverage occurred.
Independence Blue Cross updated MA11.077i to MA11.077j, adding nine new ICD-10 diagnosis codes (effective 10/01/2025) related to inflammatory breast cancer, fallopian tube conditions, and prophylactic surgery encounters. The policy reissued on 04/01/2026 to reaffirm the Company's continuing position on prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy coverage criteria without substantive changes to medical necessity standards.
Independence Blue Cross has reissued policy 11.08.19s (now version 11.08.19t) for prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy with updated ICD-10 codes effective 10/01/2025. Nine new diagnosis codes have been added to support coverage determinations, including codes for inflammatory breast cancer, genetic susceptibility to fallopian tube malignancy, and family/personal history of fallopian tube cancer. The coverage criteria and medical necessity standards remain unchanged from the prior version.
This is a provider outreach bulletin from Highmark encouraging practices to reschedule patients who missed breast cancer screening appointments during October (Breast Cancer Awareness Month) to close HEDIS BCS-E measure gaps. The policy identifies specific mammogram CPT codes and mastectomy codes that count toward the screening measure for members ages 50-74, with measurement period Oct 1, 2023 through Dec 31, 2025.
Sentara Health Plans' authorization updates effective June 1, 2025 updated criteria for benign prostatic hypertrophy treatments, cosmetic and reconstructive surgery, augmentative communication devices, hospital beds and keratoconus lenses for Commercial and Medicaid plans, and archived the photodynamic therapy, early inpatient admission and transplant rejection testing policies on June 1, 2025. The notice combined the intestinal, heart-lung and pancreas and islet cell transplant policies into a new Solid Organ Transplantation policy (Surgical 236). Separate updates removed prior authorization for 56 Medicare procedure codes, 49 Medicaid procedure codes and 48 Commercial procedure codes effective April 1, 2025.
Aetna's Breast Reduction Surgery and Gynecomastia Surgery policy (CPB 0017) was reviewed on 2026-10-26, and the source does not state what changed or give a new effective date. It sets the criteria for breast reduction (CPT 19318) to be covered for symptomatic macromastia, including documented symptoms, a 3-month trial of conservative care, a resection weight that meets the Schnur body surface area table or more than 1 kg per breast, and a negative mammogram for women 50 or older, and it treats gynecomastia surgery and liposuction-only reduction as cosmetic or experimental.
External breast prostheses are medically necessary following a medically necessary mastectomy or lumpectomy and for persons with gender dysphoria, with up to six breast prosthesis bras initially after a medically necessary mastectomy and up to six bra replacements every 12 months. One breast prosthesis per side is covered for the useful lifetime of the prosthesis, two prostheses (one per side) are covered for bilateral mastectomy or gender dysphoria, and one replacement silicone breast prosthesis is covered every 24 months. A breast prosthesis with integrated adhesive, a custom-fabricated prosthesis compared with a pre-fabricated silicone prosthesis, a prosthesis for developmental breast asymmetry, and more than one external breast prosthesis are considered not medically necessary.
Aetna considers reduction mammaplasty (CPT 19318) medically necessary for non-cosmetic indications in women age 18 or older, or once growth is complete with breast size stable for one year. For macromastia, the criteria require persistent symptoms in at least two listed body areas that are attributed to macromastia and affect daily activities for at least 1 year, documented severe breast hypertrophy in high-quality photographs, and symptoms that persist despite at least a 3-month trial of listed therapeutic measures. Gigantomastia of pregnancy is medically necessary when a listed complication is present and delivery is not imminent. Breast reduction, surgical mastectomy, or liposuction for gynecomastia is considered cosmetic, and several listed techniques are considered experimental, investigational, or unproven.
Aetna considers prophylactic mastectomy medically necessary for reduction of breast cancer risk in listed high-risk women, including women diagnosed with breast cancer at 45 years of age or younger, women with a BRCA1 or BRCA2 mutation confirmed by molecular susceptibility testing, and women who received radiation treatment to the chest between ages 10 and 30. Prophylactic bilateral oophorectomy or salpingo-oophorectomy is medically necessary for selected women with listed risk factors who meet specific family history or germline mutation criteria, and germline multigene panel testing is medically necessary once per lifetime for persons who meet one or more NCCN testing criteria for high-penetrance breast cancer susceptibility genes. Testing for BARD1, MUTYH, NBN, and other genes or indications not listed in the policy is not covered.
Effective January 22, 2026, gender reassignment surgery is considered medically appropriate for members age 18 or older who have referral letters from two qualified NYS licensed health professionals, and the policy lists the covered surgeries and services for Medicaid Managed Care Plan and Health and Recovery Plan members. The January 22, 2026 annual review moved the hormone therapy criteria to Pharmacy policies with policy intent unchanged, and a March 20, 2026 policy edit revised policy statement references for alignment, also with intent unchanged.
Independence Blue Cross reissued policy 11.08.19s on 04/01/2026 to reaffirm coverage for prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy in high-risk and moderately increased-risk individuals. Nine new ICD-10 diagnosis codes were added effective 10/01/2025 to support claims related to inflammatory breast cancer, genetic susceptibility to fallopian tube malignancies, and family/personal history of fallopian tube neoplasms. No changes to coverage criteria, CPT codes, or billing requirements were made.
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