Medicare AdvantageCoverageMedium impact
Breast Reconstruction - Medicare Advantage (Revised)
Humana·Plastic Surgery, General Surgery, Oncology·Medicare Advantage
We identified it
Jul 30, 2026
Summary
This is a new Medicare Advantage policy clarifying coverage for breast reconstruction procedures following mastectomy, trauma, or congenital abnormalities. The policy outlines that reconstruction can be performed immediately, delayed, or in staged fashion and may include revision procedures. However, the policy document provided contains only definitional/scope information without specific billing codes, prior authorization requirements, or coverage limitations that would typically trigger billing workflow changes.
Action Required
By [ASAP - within 5 business days]: Billing and clinical teams must obtain the FULL policy document from the provided Humana URL (https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a58fc53) as this summary-only version lacks critical billing information. Once full policy is retrieved, identify: (1) specific CPT codes for breast reconstruction procedures covered, (2) prior authorization requirements and submission process, (3) medical necessity documentation standards, (4) coverage limitations or exclusions, (5) applicable ICD-10 codes for diagnoses triggering coverage. Update billing system rules, encounter templates, and prior auth workflows accordingly. Flag this policy for follow-up review once complete documentation is available.