MedicaidCoverageMedium impact
Breast Procedures - MEDICAID - VIRGINIA (Revised)
Humana·VA · Plastic Surgery, General Surgery, Oncology·Medicaid
Effective date
Dec 3, 2025
We identified it
Jun 24, 2026
Summary
This is a new Humana Medicaid policy for Virginia establishing coverage criteria for breast procedures including reconstruction, implant removal, and reduction mammaplasty. The policy defines specific medical necessity requirements for breast reconstruction following mastectomy/lumpectomy, trauma, or complications, and excludes cosmetic procedures.
Action Required
Before December 3, 2025: Billing team must review all breast procedure claims for Virginia Medicaid members to ensure they meet the new medical necessity criteria. Update prior authorization processes to verify mastectomy/lumpectomy history, trauma within 12 months, or specific complications before submitting claims. Train staff that liposuction-only reduction mammaplasty and cosmetic breast asymmetry corrections are not covered.