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

Breast Procedures - MEDICAID - INDIANA (Revised)

Effective date
Oct 28, 2026
Identified
Oct 26, 2026

Summary

Humana Indiana Medicaid revised its breast procedures policy (HUM-IN-2030-002) effective 2026-10-28, establishing updated coverage criteria for breast lesion excision, reconstruction, and implant-related procedures. The policy clarifies eligibility requirements for common procedures like excision (CPT 19120, 19125), reconstruction (CPT 19325, 19342, 19350, 19380), and implant removal/revision (CPT 19328, 19330, 19370, 19371). Billing teams must verify that prior authorizations and claim submissions align with the revised criteria, particularly for cases involving fibroadenoma, atypical hyperplasia, capsular contracture, and breast implant-associated malignancies.

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What to do

Action · 7 steps
01Effective 2026-10-28: Billing team must update prior authorization templates and claim review criteria in the billing system to reflect the revised coverage determination requirements for Indiana Medicaid breast procedures.
02For breast lesion excision (CPT 19120, 19125), verify that prior authorization documentation includes biopsy results confirming atypical hyperplasia, LCIS, phyllodes tumor, or fibroadenoma (with age >35, immobile mass, poorly circumscribed mass, size >2.5 cm, or nondiagnostic biopsy), mucocele-like lesions with atypia, intraductal papilloma, radial scar, suspicious interval changes, or suspicious nipple discharge with normal imaging; alternatively document anatomic unsuitability for core/incisional biopsy for patient or lesion.
03For breast reconstruction procedures (CPT 19325, 19342, 19350, 19316, 19380), require documentation of medically necessary mastectomy, prophylactic mastectomy, trauma-related deformity, reconstructed breast complications, or congenital deformity.
04For capsulotomy, capsulectomy, and implant removal (CPT 19370, 19371, 19328, 19330), require imaging confirmation of rupture or microbiological/clinical evidence of infection; for capsular contracture, document Baker grade III or IV; for implant exposure/extrusion, document clinical findings; for BIA-ALCL or BIA-SCC, require confirmed diagnosis or document Allergan BIOCELL implant history.
05For members under age 21, flag requests for EPSDT medical necessity review.
06Update internal billing documentation and train coding/authorization staff on the new criteria to prevent claim denials.
07Verify current policy applicability with Humana prior to implementation.

Codes mentioned

191201912519316193251932819330193421935019370193711938011971

Original notice

Breast Procedures - MEDICAID - INDIANA (Revised)
mcp.humana.com · Always check the source before changing claims.
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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 - ILLINOIS (New)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 policiesIN policy changesPlastic SurgeryGeneral SurgeryOncologyCode 19120Code 19125Code 19316Code 19325Code 19328Code 19330Code 19342Code 19350Code 19370Code 19371Code 19380Code 11971

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