Medicare AdvantageCoverageMedium impact
Breast Excision and Mastectomy - Medicare Advantage (Revised)
Humana·General Surgery, Oncology, Plastic Surgery·Medicare Advantage
Effective date
May 1, 2026
We identified it
Jun 24, 2026
Summary
This is a revised Medicare Advantage policy for breast excision and mastectomy procedures that establishes detailed medical necessity criteria for breast lesion excisions and mastectomy procedures. The policy provides comprehensive coverage determination guidelines for various breast procedures including excisional biopsies, lumpectomies, and mastectomies.
Action Required
Before May 1, 2026: Billing team must review and update documentation requirements for breast excision procedures (CPT 19120, 19125) and mastectomy procedures (CPT 19300, 19301, 19302) to ensure they meet the specific medical necessity criteria outlined in the policy. Update prior authorization processes to align with the detailed coverage determination requirements for Medicare Advantage plans.