Medicare AdvantageCoverageHigh impact
MA11.030j, Reconstructive Breast Surgery
Independence Blue Cross·Plastic Surgery, General Surgery, Oncology·Medical Policy
Effective date
Dec 8, 2026
We identified it
Sep 9, 2026
Summary
Independence Blue Cross Medicare Advantage is revising coverage for acellular dermal matrices (ADM) in reconstructive breast surgery effective 12/08/2026. Eight HCPCS codes are being removed from this policy and reclassified as experimental/investigational or moved to the Bioengineered Skin Substitutes policy (MA11.015). Additionally, Q4130 (Strattice) and Q4433 (361 hct/p skin substitute) are changing from medically necessary to experimental/investigational status. Billing teams must stop using these codes for reconstructive breast surgery claims and verify coverage under the new policy before claim submission.
Action Required
By December 1, 2026 (one week before effective date): Billing team must update all billing systems and EMR software to remove the following HCPCS codes from the Reconstructive Breast Surgery policy (MA11.030j): C9358, C9360, C9364, Q4134, Q4142, Q4143, Q4193, Q4107, Q4130, and Q4433. These codes are now classified as experimental/investigational or have been moved to the Bioengineered Skin Substitutes policy (MA11.015). For any reconstructive breast surgery claims submitted on or after 12/08/2026, verify code coverage under MA11.015 before billing. For Q4107 (Graftjacket), confirm the procedure qualifies as a diabetic lower extremity ulcer claim under MA11.015 (not reconstructive breast surgery). Update claim rejection protocols to identify these codes on breast surgery claims and route for manual review or denial. Notify all providers and surgeons in plastic surgery and general surgery departments of the policy changes. Failure to update billing rules will result in automatic denials for claims using these codes for reconstructive breast surgery after 12/08/2026.