Breast Procedures - MEDICAID - VIRGINIA (Revised)

By 10/28/2026: Billing team should update claim submission workflows and prior authorization protocols to reflect the coverage determination criteria specified in this revised policy for Virginia Medicaid members. Specifically: (1) Verify that breast lesion excision claims (CPT 19120, 19125) include documentation supporting one of the listed criteria (e.g., biopsy results indicating atypical hyperplasia, LCIS, phyllodes tumor, fibroadenoma, or imaging-biopsy discordance). (2) Ensure breast reconstruction claims (CPT 19325, 19342, 19350, 19380, etc.) include documentation of medical necessity (mastectomy, prophylactic mastectomy, trauma, congenital deformity, or reconstruction-related complications). (3) For capsulotomy, capsulectomy, and implant removal (CPT 19370, 19371, 19328, 19330), confirm claims include documentation of Baker grade III–IV capsular contracture, implant rupture (MRI/ultrasound confirmed), implant exposure/extrusion, or infection with microbiological confirmation. (4) For BIA-ALCL or BIA-SCC implant removal (CPT 19371), require confirmed diagnosis documentation or Allergan BIOCELL implant identification. (5) Update billing software to reflect these coverage requirements and flag non-compliant claims before submission to reduce denials. Front desk and clinical staff should ensure all encounter forms and surgical records capture the relevant clinical indicators required under each coverage criterion. Contact Humana's Coverage Policy Adoption Forum or provider relations if clarification is needed on specific scenarios.