Skip to main content
HealthPartners

Coverage criteria policies

Breast Pumps – Iowa - North Dakota - South Dakota

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for the purchase of a dual manual breast pump (E0602) or a standard, dual electric breast pump (E0603).

Prior authorization is required for rental of a heavy duty, hospital grade electric breast pump (E0604). Please see related content at right for review form.

Coverage

Breast pumps are generally covered under Preventive Benefits per the indications below.

Indications that are covered

  1. Purchase of one dual manual (E0602) or one standard, dual electric breast pump (E0603) is covered per pregnancy resulting in birth for all women who choose to breast feed.
  2. Supplies necessary for the use of a breast pump, such as tubing (A4281) an adapter (A4282) and breast shields (A4284) are covered as needed.
  3. Rental of a heavy duty, hospital grade electric breast pump (E0604) and purchase of necessary supplies is covered when ordered by a health care provider as medically necessary during the time a mother and infant are separated because the infant remains hospitalized upon the mother’s discharge.
  4. Once the baby is discharged, the continued rental of a hospital grade electric breast pump is not considered medically necessary. The purchase of a standard electric breast pump (E0603) will then be covered as stated above.

Indications that are not covered

  1. Purchase of a heavy duty, hospital grade electric breast pump (E0604) is not covered as it is not medically necessary.
  2. Rental of a heavy duty, hospital grade electric breast pump (E0604) is not covered after the baby is discharged from the hospital.
  3. Replacement supplies for comfort and convenience (Cap for breast pump bottle, replacement - A4283, Polycarbonate bottle, replacement - A4285 and Locking ring, replacement - A4286) and milk storage products are not covered as they are not medically necessary.

Definitions

A breast pump is a mechanical device used to extract milk from a lactating mother.

There are 3 basic types:

  1. Manual Breast Pump (E0602): A non-electric pump that works by vacuum suction. This is a single use item and is available for purchase only.
  2. Standard, Electric Breast Pump (E0603): An electric pump that works by creating pulsating suction, usually by pneumatic action against a diaphragm. This is a single use item and is available for purchase only.
  3. Hospital Grade Heavy Duty Electric Breast pump (E0604): A piston operated electric pump with pulsatile vacuum suction and release cycles. This item is available as a rental item only.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

    Codes

    Description

    E0602

    Breast pump, manual, any type

    E0603

    Breast pump, electric (AC and/or DC), any type

    E0604

    Breast pump, hospital grade, electric (AC and/or DC), any type

    A4281

    Tubing for breast pump, replacement

    A4282

    Adapter for breast pump, replacement

    A4283

    Cap for breast pump bottle, replacement

    A4284

    Breast shield and splash protector for use with breast pump, replacement

    A4285

    Polycarbonate bottle for use with breast pump, replacement

    A4286

    Locking ring for breast pump, replacement

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Vendor

  • Breast Pumps must be obtained from contracted, network providers for in-network benefits to apply. All other providers, including retail or online vendors, are considered out of network.
  • Please check your plan documents to determine whether you have out of network benefits for this service, as Preventive Services benefits may be different from your other benefits.

References

  1. Abrams, S. A., & Hurst, N. M. Breastfeeding the preterm infant. In: UpToDate, Garcia-Prats, J. A. (Ed), UpToDate, Waltham, MA. (Accessed on July 7, 2017).
  2. Amir, L. H., Marinelli, K. A., Bunik, M., Noble, L., Brent, N., Grawey, A. E. … Seo, T. (Revised 2014). Academy of Breastfeeding Medicine Clinical Protocol #4: Mastitis. Breastfeeding Medicine, 9(5), 239-43. DOI: 10.1089/bfm.2014.9984
  3. Jadcherla, S. R. Neonatal oral feeding difficulties due to sucking and swallowing disorders. In: UpToDate, Abrams, S. A. (Ed), UpToDate, Waltham, MA. (Accessed on July 7, 2017).
  4. Trangle, M., Gursky, J., Haight, R., Hardwig, J., Hinnenkamp, T., Kessler, D., … Myszkowski, M. Institute for Clinical Systems Improvement. Adult Depression in Primary Care. Updated March 2016.

Go to

Policy activity

  • 04/26/2012 - Date of origin
  • 07/01/2017 - Effective date
Review date
  • 07/2017

Related content