Medicare AdvantageCoverageMedium impact
MA11.077h, Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
Independence Blue Cross·OB-GYN, General Surgery, Oncology·Medical Policy
Effective date
Apr 30, 2025
We identified it
Jun 19, 2026
Summary
Policy MA11.077h regarding prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy was reissued effective 04/30/2025. This recent update supersedes older guidance on these preventive surgical procedures. The billing team must review the full policy text to identify any changes to coverage criteria, prior authorization requirements, or billing code applications for these procedures.
Action Required
By 05/15/2025: Billing and clinical teams must obtain and review the complete policy text from the provided URL to identify specific changes from the prior version. Compare the reissued MA11.077h policy against any previously used version to identify: (1) changes to medical necessity criteria, (2) prior authorization requirements, (3) any affected CPT codes (likely 19303, 19304, 58150, 58152, 58200, 58210 or similar surgical codes), and (4) documentation requirements. Update billing system rules, prior authorization workflows, and provider education materials accordingly. Failure to implement required changes may result in claim denials or improper reimbursement for affected procedures.