Restricted Breast Cancer Surgery Facilities

It is the policy of the New York State Department of Health (NYSDOH) that Medicaid and Health and Recovery Plan (HARP) members receive breast cancer surgery at high-volume facilities. Research shows that five-year survival rates are higher for patients who have breast cancer surgery performed at high-volume facilities. A high-volume facility is one that performs 30 or more mastectomy and lumpectomy procedures annually over a three-year period. 

The NYSDOH annually reviews the surgical volumes of all hospitals and ambulatory surgical centers and releases an updated list of low-volume facilities.  You can see a list of hospital and ambulatory surgery centers on the NYSDOH website where Medicaid will not pay for breast cancer surgery (effective April 1, 2026). 

The policy does not restrict a facility's ability to provide diagnostic or excisional biopsies and post-surgical care (chemotherapy, radiation, reconstruction, etc.). 

Preauthorization requests and claims for mastectomies and lumpectomies submitted by these low-volume facilities will be denied. For mastectomy and lumpectomy procedures related to breast cancer, Medicaid/HARP members should be directed to high-volume providers in their area.  Any payments issued by EmblemHealth may be subject to recoupment.