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Breast Reconstruction - Medicare Advantage (Revised)
Effective date
Aug 3, 2026
Identified
Jul 30, 2026
Summary
Humana Medicare Advantage has revised its breast reconstruction coverage policy (effective 08/03/2026) to clarify medical necessity criteria for reconstruction procedures following mastectomy, trauma, or congenital abnormalities. The policy applies MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction and establishes criteria for determining coverage of implant removal, reduction mammaplasty, and related procedures. Billing teams must identify the appropriate MAC jurisdiction for each claim and apply the correct LCD requirements.
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What to do
Action · 5 steps
01Billing team must map all service locations to their corresponding MAC jurisdiction (J5, J8, J15, JE, JF, JH, JL, JJ, JM, JN) as listed in the policy.
02For each jurisdiction, download and implement the applicable LCD requirements from the CMS Medicare Coverage Database (reference LCD numbers: L39051, L39506, L35163, L35090, L33428, L38914, and LCA numbers: A58774, A59299, A57221, A56587, A56658, A58573).
03Update billing system rules to require prior authorization workflows for CPT codes 19328, 19330, 19370, 19371, and 19318 based on MAC-specific medical necessity criteria.
04Providers must document medical necessity for breast implant removal/revision and reduction mammaplasty claims per LCD L33428 criteria for jurisdictions J6/JK.
05Train billing and prior authorization staff on jurisdiction-specific LCD requirements.
If missed: Failure to apply correct MAC-specific criteria will result in claim denials or payment delays.
Codes mentioned
1932819330193701937119318
Original notice
Breast Reconstruction - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.
Related changes
See all Humana changes →Breast 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 · MedicaidBreast Procedures - MEDICAID - INDIANA (Revised)HighEffective Oct 28, 2026 · MedicaidBrowse every Humana change in the policy list
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