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Breast Procedures - MEDICAID - MICHIGAN (New)
Effective date
Oct 28, 2026
Identified
Oct 26, 2026
Summary
Humana Medicaid in Michigan has published a new breast procedures coverage policy (HUM-MI-2030-000) effective 2026-10-28 that establishes specific medical necessity criteria for breast lesion excision, breast reconstruction, implant removal/revision, and implant-associated malignancy procedures. The policy defines covered CPT codes and clinical indications (e.g., atypical hyperplasia, fibroadenoma >2.5 cm, capsular contracture Baker III-IV, BIA-ALCL/BIA-SCC) that must be met for claims approval.
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What to do
Action · 6 steps
01Effective 2026-10-28: Billing team must implement this new Michigan Medicaid breast procedures policy in the billing system and prior authorization workflow.
02Update claims submission rules to require medical necessity documentation for all breast procedure codes (19120, 19125, 19316, 19325, 19328, 19330, 19342, 19350, 19370, 19371, 19380, 11971) matching the specific clinical criteria stated in the Coverage Determination section (e.g., atypical hyperplasia, fibroadenoma with documented size >2.5 cm or immobility, capsular contracture Baker III-IV, implant rupture confirmed by imaging, BIA-ALCL/BIA-SCC confirmed diagnosis).
03Configure prior authorization requirements to enforce that excision of breast lesions (19120, 19125) require core needle or incisional biopsy results or documented anatomical contraindications; breast reconstruction (19325, 19342, 19350, 19316, 19380) require medically necessary mastectomy, prophylactic mastectomy, trauma, or congenital deformity; and implant removal (19328, 19330, 19370, 19371) require Baker III-IV contracture, implant rupture, exposure/extrusion, or refractory infection with microbiological confirmation.
04Providers and coding staff should reference the policy's clinical indicators and link supporting documentation (biopsy histology, imaging reports, microbiological culture results, BIA-ALCL/BIA-SCC confirmed diagnosis) to each claim to avoid denials.
05For members under age 21, note that requests are reviewed under EPSDT (Early and Periodic Screening, Diagnostic and Treatment) requirements.
06Claims submitted without matching clinical criteria or required supporting documentation will be denied.
Codes mentioned
119711912019125193161932519328193301934219350193701937119380
Original notice
Breast Procedures - MEDICAID - MICHIGAN (New)
mcp.humana.com · Always check the source before changing claims.
Related changes
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