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HealthPartners

Coverage criteria policies

Breast pumps

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 will be used to determine your coverage.

Prior Authorization requirements and coverage vary depending upon the member’s plan. Please call Member Services to verify which section of the policy applies for your specific plan on the date of service requested. The Member Services phone number is listed on the back of your ID card (or you may call 952-883-5000 or 800-883-2177).

Section 1

This section applies to Non-Grandfathered Plans upon renewal date after the Affordable Care Act Coverage applies

Please call Member Services to determine whether and when this section applies to you.

Administrative Process

Prior authorization is not required for the purchase of a 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 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.

Section 2

This section applies to Grandfathered Plans and other plans before the Affordable Care Act Coverage applies

Please call Member Services to determine whether and when this section applies to you.

Administrative Process

Prior Authorization is required for all types of breast pumps.

Coverage

Rental of a heavy duty, hospital grade electric breast pump (E0604) is generally covered under the Durable Medical Equipment benefit subject to the indications listed below.

Indications that are covered

Rental of a heavy duty, hospital grade electric breast pump (E0604), the initial accessory kit, and replacement of tubing (A4281) and adapter (A4282) are covered when one of the following apply:

  1. For the period of time that a mother and infant are separated due to either of the following:
    1. Mother has been discharged following delivery and newborn remains hospitalized; or
    2. Any hospitalization of the infant up to six months of age.
  2. While a breastfeeding mother is being treated for mastitis.
  3. When breastfeeding would have an adverse effect on the infant due to medication taken by the mother.
  4. For infants who have congenital disorders that interfere with feeding such as cleft palate, Down syndrome or cerebral palsy.
  5. For premature infants, defined as less than 37 weeks gestation, with poor sucking reflex or the inability to suck.

Indications that are not covered

  1. Purchase of any type of breast pump is not covered as it is not medically necessary.
  2. 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.
  3. When no medical conditions listed as covered above are present, but infant and mother are having difficulty establishing and maintaining breastfeeding, including inadequate milk production.
  4. When the mother is separated from the infant due to the mother being hospitalized, returning to work or vacation, etc.
  5. Manual (E0602) or standard electric breast pumps (E0603).

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. 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

  • 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.

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Policy activity

  • 04/26/2012 - Date of origin
  • 07/01/2017 - Effective date
Review date
  • 07/2018

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