MedicaidCoverageMedium impact
Breast Procedures - MEDICAID - SOUTH CAROLINA (Revised)
Humana·SC · Plastic Surgery, General Surgery, Oncology·Medicaid
Effective date
Sep 3, 2025
We identified it
Jun 24, 2026
Summary
Humana Medicaid South Carolina has updated their breast procedures policy effective September 3, 2025, establishing specific coverage criteria for breast reconstruction, implant procedures, and reduction mammaplasty. The policy clarifies when these procedures are covered following mastectomy, lumpectomy, or trauma, and excludes coverage for cosmetic indications.
Action Required
Before September 3, 2025: Billing team must update system documentation requirements for breast procedure claims to verify medical necessity criteria are met (mastectomy, lumpectomy, or trauma within 12 months). Update encounter forms to remind providers that reduction mammaplasty requires medical director review when performed prior to nipple-sparing mastectomy. Note that liposuction-only reduction mammaplasty is not covered. Claims not meeting medical necessity criteria will be denied.