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Breast Excision and Mastectomy - Medicare Advantage (Revised)
Act
by Aug 3, 2026
Effective date
Aug 3, 2026
Identified
Jul 30, 2026
Summary
Humana Medicare Advantage has updated its Breast Excision and Mastectomy policy (HUM-1254-009) effective 08/03/2026. This revised policy clarifies coverage criteria for breast lesion excisions (CPT 19120, 19125), partial mastectomies (CPT 19301, 19302), and gynecomastia mastectomy (CPT 19300) across multiple MAC jurisdictions. The policy establishes specific medical necessity criteria based on biopsy results, lesion characteristics, and anatomical considerations, and applies jurisdiction-specific Local Coverage Determinations (LCDs) for Medicare Administrative Contractors.
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What to do
by Aug 3, 2026 · 7 steps
01Billing team must update coding and prior authorization workflows to align with revised medical necessity criteria for breast procedures.
02For CPT 19120/19125 (breast lesion excision): implement documentation requirements to capture biopsy findings (atypical hyperplasia, LCIS, phyllodes tumor, fibroadenoma characteristics, intraductal papilloma, radial scar, nipple discharge status) or anatomical contraindications to biopsy.
03For CPT 19301/19302 (partial mastectomy): ensure documentation includes biopsy-proven malignancy status (DCIS, Stage I-II cancer).
04For CPT 19300 (gynecomastia mastectomy): apply LCD L39051 criteria for jurisdictions J6/JK/JJ/JM, or applicable MAC LCD for other jurisdictions.
05Billing team must map submitted claims to correct MAC jurisdiction (J5, J8, J15, JE, JF, JH, JL, JN) and apply corresponding LCD.
06Update encoder software and claim submission rules to reflect MAC-specific LCD requirements.
07Providers must document all pertinent clinical findings on operative reports.
If missed: Failure to align with jurisdiction-specific LCD requirements will result in claim denials.
Codes mentioned
1912019125193001930119302
Original notice
Breast Excision and Mastectomy - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.
Related changes
See all Humana changes →Breast Excision and Mastectomy - Medicare Advantage (Revised)MediumEffective May 1, 2026 · Medicare AdvantageBreast Procedures - MEDICAID - VIRGINIA (Revised)MediumEffective Oct 28, 2026 · MedicaidBreast Procedures - MEDICAID - SOUTH CAROLINA (Revised)MediumEffective Oct 28, 2026 · MedicaidBreast Procedures - MEDICAID - MICHIGAN (New)HighEffective Oct 28, 2026 · MedicaidBrowse every Humana change in the policy list
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