Medicare AdvantageCoverageHigh impact
Breast Excision and Mastectomy - Medicare Advantage (Revised)
Humana·General Surgery, Oncology·Medicare Advantage
We identified it
Jul 30, 2026
Summary
This Medicare Advantage policy revision addresses coverage criteria for breast excision and mastectomy procedures, including excisional biopsy and breast-conserving surgery (BCS). The policy clarifies surgical decision-making based on lesion characteristics, size, and clinical context. However, the provided content is truncated and does not include complete coverage criteria, billing codes, or specific reimbursement guidance needed for full implementation.
Action Required
CRITICAL: Billing team must obtain the COMPLETE policy document from Humana immediately. The provided summary is incomplete and truncated mid-sentence. Required actions: (1) Request full policy text from Humana at dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a58fbfc or contact Humana provider relations; (2) Once received, identify specific CPT codes (likely 19120, 19125, 19301, 19302, 19303, or similar breast surgery codes) that are affected; (3) Determine if prior authorization is required for excisional biopsy vs. BCS; (4) Update billing system rules and documentation requirements in the EMR; (5) Communicate any changes to surgical providers and schedulers. Do NOT process claims based on this incomplete summary. Failure to obtain and implement the complete policy may result in claim denials or improper reimbursement.