MedicaidPrior AuthMedium impact
Effective 08/31/26: Criteria Change for Certain Breast Reduction Mammoplasty and Gynecomastia Surgery Procedures
Ambetter·TX · Plastic Surgery, General Surgery·Medical Policy
Effective date
Aug 31, 2026
We identified it
Aug 26, 2026
Summary
Effective August 31, 2026, Superior HealthPlan is retiring its clinical policy for breast reduction mammoplasty (CPT 19318) and gynecomastia surgery (CPT 19300) and replacing it with new medical necessity review criteria. For Medicaid plans, criteria will reference the Texas Medicaid Provider Procedures Manual; for CHIP and Ambetter plans, criteria will use Change Healthcare's InterQual guidelines. Prior authorization requirements remain in effect.
Action Required
By August 31, 2026: Billing and authorization teams must update prior authorization submission workflows to reflect new criteria sources. For Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) claims for CPT 19300 and 19318: reference the Texas Medicaid Provider Procedures Manual for medical necessity criteria. For CHIP and Ambetter from Superior HealthPlan/Ambetter Health Solutions claims: reference Change Healthcare's InterQual criteria (available upon request from Superior). Update internal policy documentation and staff training materials to reflect the criteria change. Contact Superior's Prior Authorization department at 1-800-218-7508 if clarification on specific criteria is needed. Continue requiring prior authorization for both procedure codes as stated. Failure to apply updated criteria may result in claim denials or authorization delays.