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HumanaMedicaid · Coverage · Medicaid · IL · Plastic Surgery, General Surgery, OncologyHigh impact

Breast Procedures - MEDICAID - ILLINOIS (New)

Effective date
Oct 28, 2026
Identified
Oct 26, 2026

Summary

Humana Illinois Medicaid has adopted a new breast procedures coverage policy (HUM-IL-2030-000) effective 2026-10-28, establishing medical necessity criteria for breast lesion excision, breast reconstruction, capsulotomy/capsulectomy, implant removal, and implant reinsertion. The policy specifies eligible diagnoses, surgical procedures, and CPT codes for coverage determination under Illinois Medicaid.

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What to do

Action · 5 steps
01Effective 2026-10-28: Billing team must implement this new coverage policy for all Illinois Medicaid claims involving breast procedures.
02Verify that billing software is updated to recognize the covered CPT codes (11971, 19120, 19125, 19316, 19325, 19328, 19330, 19342, 19350, 19370, 19371, 19380) and enforce the stated medical necessity criteria before claim submission.
03Prior to submitting claims, providers and clinical staff must document that procedures meet at least one criterion listed in the Coverage Determination section for each category (breast lesions, breast reconstruction, capsulotomy/capsulectomy/implant removal, or implant-associated malignancy removal).
04Claims submitted without documented medical necessity aligned to policy criteria may be denied.
05Confirm that front-desk and authorization staff are aware of the effective date and new policy requirements for Illinois Medicaid members.

Codes mentioned

119711912019125193161932519328193301934219350193701937119380

Original notice

Breast Procedures - MEDICAID - ILLINOIS (New)
mcp.humana.com · Always check the source before changing claims.
View original ↗

Related changes

See all Humana changes →
Breast Procedures - MEDICAID - VIRGINIA (Revised)MediumEffective Oct 28, 2026 · MedicaidBreast Procedures - MEDICAID - MICHIGAN (New)HighEffective Oct 28, 2026 · MedicaidBreast Procedures - MEDICAID - INDIANA (Revised)HighEffective Oct 28, 2026 · MedicaidBreast Procedures - MEDICAID - SOUTH CAROLINA (Revised)MediumEffective Oct 28, 2026 · MedicaidBrowse every Humana change in the policy list

Related policy hubs

Humana policiesIL policy changesPlastic SurgeryGeneral SurgeryOncologyCode 11971Code 19120Code 19125Code 19316Code 19325Code 19328Code 19330Code 19342Code 19350Code 19370Code 19371Code 19380

Summaries are AI-assisted. Always confirm against the original payer notice.

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