MedicaidCoverageHigh impact
Restricted Breast Cancer Surgery Facilities
EmblemHealth·NY · General Surgery, Oncology, Plastic Surgery·Provider News
Effective date
Apr 1, 2026
We identified it
Jul 17, 2026
Summary
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.
Action Required
Before April 1, 2026: (1) Billing team must verify your facility's breast surgery volume on the NYSDOH website to confirm high-volume or low-volume status. (2) If low-volume facility: Implement workflow to identify all Medicaid/HARP mastectomy and lumpectomy cases (CPT 19301-19312) and redirect patients to high-volume providers in their area before scheduling. (3) Update preauthorization and billing system rules to automatically flag and deny claims for CPT 19301-19312 from this facility for Medicaid/HARP members. (4) Brief clinical staff and front desk to inform patients of facility restrictions and provide referral list of high-volume providers. (5) If high-volume facility: No action required for coverage eligibility, but confirm high-volume status and maintain documentation. Consequence: Claims for breast cancer surgery submitted by low-volume facilities will be denied and subject to recoupment by EmblemHealth.