What this is, in plain language
Surgery to remove a lump or other abnormal tissue from the breast, usually to test it or because it needs to come out.
Why a clinician orders it
A suspicious finding on exam or imaging, or a growing benign lump such as a fibroadenoma.
Medical necessity — what insurers usually look at
Usually covered, but many plans require prior authorization for outpatient surgery. Pathology (88305) is typically billed separately.
New to this? Read what medical necessity means and how to appeal a denial.
Documentation to ask about
- ✓Imaging and exam findings
- ✓Prior auth approval if required
- ✓In-network facility and surgeon
- ✓Pathology billing expectations
Questions for your provider
- ?Has prior authorization been approved in writing?
- ?Will pathology be billed separately, and is that lab in-network?
Why this code is in our seed set
Common breast surgery code; validated against the CMS Top 200 and ACS/ASBrS guidance.
Validated against
- •CMS Top 200 Level I CPT Codes Ranked by Services
- •AMA CPT code 19120 descriptor
- •American Society of Breast Surgeons guidance
Terms you'll see
Prior AuthorizationRead more →
Some services may need plan approval before they are performed.
Medical NecessityRead more →
The insurer is reviewing whether the service is clinically appropriate for your situation.
Important: AuraCode is an educational tool. It does not provide medical, legal, or insurance advice, claims decisions, or approval guarantees. Final coverage depends on your specific plan, eligibility, diagnosis, submitted documentation, and your insurer's review.