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HealthPartners

Coverage criteria policies

Breast pumps – Minnesota Health Care Programs

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

  • No Prior authorization for purchase of one electric, battery-operated (E0603) or manual / hand-held breast pump (E0602) when prescribed by a HealthPartners Plan physician, certified nurse midwife, or nurse practitioner.
  • Prior authorization is required after initial 3 month rental period for rental of Hospital Grade electric breast pumps (E0604).

Coverage

A breast pump is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. Breast pumps are covered when ordered by a physician, certified nurse midwife, or nurse practitioner for any nursing mother experiencing separation from her infant because of work, school, illness or any other medical reason.
  2. The purchase of an electric breast pump (E0603) is limited to one every three years.
  3. Hospital Grade electric pumps (E0604) are covered as a rental item only.

Indications that are not covered

  1. The purchase of more than one electric breast pump (E0603) within three years.
  2. The purchase of a Hospital Grade electric breast pump (E0604).

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

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. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

  • For in-network benefits to apply, item must be received from a contracted vendor or provider.

References

  1. Minnesota Health Care Programs (MHCP) Provider Manual: Obstetric Services and HIV Counseling. Revised: 06-14-2016

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Policy activity

  • 07/01/1995 - Date of origin
  • 07/01/2017 - Effective date
Review date
  • 07/2018

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