Medicare AdvantageCoverageMedium impact
Breast Imaging - Medicare Advantage (Revised)
Humana·Radiology, Oncology, Family Medicine +2 more·Medicare Advantage
Effective date
Jul 1, 2026
We identified it
Oct 6, 2026
Summary
This is a revised Medicare Advantage breast imaging coverage policy (effective 2026-07-01) that establishes medical necessity criteria for mammography, digital breast tomosynthesis, breast MRI, and ultrasound across Humana plans. The policy clarifies screening breast MRI eligibility based on genetic variants, family history, lifetime risk assessment (≥20%), male breast cancer history, or prior chest radiation. Billing teams must verify current applicability and confirm whether this practice's billing workflows align with the specified coverage criteria and applicable MAC jurisdictions.
Action Required
Already effective 2026-07-01 (historical material newly discovered 2026-10-06): Billing and clinical teams should verify whether current prior authorization and claim submission workflows align with this Humana Medicare Advantage breast imaging policy. Confirm that: (1) Screening breast MRI requests are evaluated against the stated genetic criteria (ATM, CDH1, CHEK2, PALB2, STK11 at age 30+; BARD1, RAD51C, RAD51D at age 40+; BRCA1, BRCA2 at age 25+; TP53 at age 20+; NF1 ages 30–50; PTEN at age 30+), untested first-degree relative status, lifetime risk ≥20% via validated tools, male breast cancer family history, or prior chest radiation (ages 10–30); (2) Diagnostic mammography (77065–77067, G0279) and diagnostic breast MRI (77046–77049, C8903, C8905, C8906, C8908) submissions reference applicable MAC LCDs (L33950 for KY/OH; L33585 for IL/MN/WI and CT/MA/ME/NH/NY/RI/VT) or NCD coverage rules; (3) Ultrasound requests (76641, 76642, 76999) align with NCD 220.5 criteria. Review the Related CMS Documents section to confirm which MAC jurisdiction applies to your practice geography and whether any local coverage articles supersede this policy. No source-stated deadline applies; this guidance is now in effect and should be treated as current policy pending any subsequent Humana updates.