Breast Reconstructive Surgery, Implant Management and Reduction Mammoplasty (Special Alert)
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This policy governs coverage and authorization for breast reconstructive surgery, implant management, and reduction mammoplasty for Providence Health Plan members and providers. It communicates a correction to previously intended updates and instructs providers to resubmit prior authorizations or appeals if negatively affected.
Updates from the May 2025 Provider Alert to the MP58 policy (effective 7/1/2025) were not published as intended and have now been corrected and are showing on the policy with effective date 3/16/2026.
Required Provider Actions and Appeals
Resubmit prior authorizations or appeal impacted denials
If a provider believes the May 2025 updates (intended effective 7/1/2025) that were not published previously have negatively affected a prior authorization, the provider must resubmit the prior authorization request or submit a reconsideration/appeal for a denied authorization.
- Resubmit the PA request if it was negatively impacted by the earlier omission.
- If the authorization was denied, submit a reconsideration/appeal for the denied authorization.
Action required after corrected policy publication
The policy correction restores the May 2025 Provider Alert updates to MP58 with effective date 3/16/2026; providers affected by the publication omission should act to have prior authorizations reconsidered.
- Recognize that updates intended for 7/1/2025 are now published effective 3/16/2026.
- Initiate resubmission or reconsideration promptly to avoid coverage delays.
Supplemental: resubmission and appeal guidance
Supplemental guidance: when the publication omission may have changed prior-authorization outcomes, providers should resubmit the PA or file a reconsideration/appeal as described in the Special Alert.
- Use the corrected policy effective date (3/16/2026) when preparing resubmissions or appeals.
- Include reference to the Special Alert noting the earlier updates were not published as intended.
Resubmit impacted PAs and seek reconsideration for denials
High-priority reminder: prior authorization requests that were negatively impacted by the earlier omission should be resubmitted; denied authorizations may be reconsidered or appealed per the Special Alert.
- Resubmit affected PAs or submit reconsideration/appeals for denials.
- Reference the Special Alert correcting the publication with effective date 3/16/2026.
Policy Background and Correction Notice
This is a special alert correcting the publication status of updates to the Breast Reconstructive Surgery, Implant Management and Reduction Mammoplasty (MP58) policy. Updates that were communicated in the May 2025 Provider Alert with an intended effective date of 7/1/2025 did not get published as anticipated and have now been corrected on the policy with an effective date of 3/16/2026.
The scope of this notice covers coverage and authorization for breast reconstructive surgery, implant management, and reduction mammoplasty for Providence Health Plan members and providers and informs stakeholders of the corrected effective date and remediation steps when prior authorizations may have been affected.
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