Effective 08/31/26: Criteria Change for Certain Breast Reduction Mammoplasty and Gynecomastia Surgery Procedures

Date: 07/22/26

Effective August 31, 2026, Superior HealthPlan will utilize different medical necessity review criteria due to clinical policy retirement for Reduction Mammoplasty and Gynecomastia Surgery Procedures for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter from Superior HealthPlan and Ambetter Health Solutions members.

Please note the impacted procedures below and criteria for each product.

Superior ensures medical necessity review criteria are current and appropriate for members and the scope of services provided.

Applicable Products: Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS)

Procedure Code	Description	Criteria
19300	Mastectomy for gynecomastia	Texas Medicaid Provider Procedures Manual
19318	Breast reduction

 

Applicable Products: CHIP, Ambetter Health

Procedure Code	Description	Criteria
19300	Mastectomy for gynecomastia	Change Healthcare’s InterQual criteria, proprietary, but available upon request.
19318	Breast reduction

To review prior authorization requirements, please visit Superior’s Prior Authorization webpage.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.