Electric Breast Pumps

Policy ID: E-37-020

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: May 14, 2025

Revision Effective Date: July 07, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description:

A breast pump is a device used to extract milk from the breast of a lactating mother for infant feeding when the mother cannot be present at feeding time or when the infant is too sick or too weak to suck.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Rental of an electric breast pump is covered when any ONEof these criteria is met:

A breast pump is covered for the period of time that a newborn is detained in the hospital after the mother is discharged. Once the newborn is discharged, the breast pump will no longer be covered; or
A breast pump will be covered for babies who have congenital anomalies that interfere with feeding. Rental of the breast pump will be covered for the first month after the baby is discharged from the hospital. When a breast pump is utilized for longer than this specified time, its medical necessity should be determined on an individual consideration basis. The purchase of a breast pump will be covered in cases where purchase of the device is more economical than the rental.

Procedure Codes

E0603

E0604

In lieu of an electric breast pump, purchase of a manual breast pump is eligible for coverage when one of the above criteria is met.

Procedure Code

E0602

Accessories are considered eligible for benefits when the purchased breast pump is eligible for benefits.

Procedure Codes

A4281

A4282

A4283

A4284

A4285

A4286

When the above criteria are met, breast pumps meet the definition of DME and payment may be made for a breast pump according to the member's DME benefits.

Breast pumps and accessories not qualifying for coverage in accordance with the above criteria do not meet the definition of durable medical equipment (DME). Therefore, they are not covered under the member's contract.

The criteria above regarding an electric breast pump, a manual breast pump and accessories does not apply to those groups that follow the Women's Health Federal Mandate effective August 1, 2012.

Procedure Codes

A4281

A4282

A4283

A4284

A4285

A4286

E0602

E0603

E0604

Disposable collection and storage bag for breast milk are considered a convenience item and are non-covered.

Procedure Code

A4287

Quantity Level Limits forreplacement equipment and supplies related to electric breast pumps:

PROCEDURE CODE

DEFINITION

QUANTITY LEVEL LIMIT APPLIED

A4281

Tubing for breast pump, replacement

2 times within 12 months from the breast pump date of service

A4282

Adapter for breast pump, replacement

2 times within 12 months from the breast pump date of service

A4283

Cap for breast pump bottle, replacement

2 times within 12 months from the breast pump date of service

A4284

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

2 times within 12 months from the breast pump date of service

A4285

Polycarbonate bottle for use with breast pump, replacement

2 times within 12 months from the breast pump date of service

A4286

Locking ring for breast pump, replacement

2 times within 12 months from the breast pump date of service

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

Links

References (PDF)

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Update on 2-25-2020 updated language

Internal Medical Policy Committee 3-17-2021 Coding update - Added A4281, A4282, A4283, A4284, A4285, A4286

Internal Medical Policy Committee 3-23-2022 Annual Review, no change in criteria

Internal Medical Policy Committee 3-23-2023 Annual Review, no change in criteria

Added Policy Application

Internal Medical Policy Committee 5-13-2025 Revision with Coding effective July 07, 2025

Added statement regarding disposable collection/storage bags and;
Added Procedure Code A4287

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-37-019

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: March 08, 2021

Revision Effective Date: May 03, 2021

Last Reviewed: March 23, 2023

Archived Date: July 06, 2025

Applies To: Commercial and Medicaid Expansion

Description

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Rental of an electric breast pump is covered when any ONE of these criteria is met:

A breast pump is covered for the period of time that a newborn is detained in the hospital after the mother is discharged. Once the newborn is discharged, the breast pump will no longer be covered; or
A breast pump will be covered for babies who have congenital anomalies that interfere with feeding. Rental of the breast pump will be covered for the first month after the baby is discharged from the hospital. When a breast pump is utilized for longer than this specified time, its medical necessity should be determined on an individual consideration basis. The purchase of a breast pump will be covered in cases where purchase of the device is more economical than the rental.

Procedure Codes

E0603

E0604

In lieu of an electric breast pump, purchase of a manual breast pump is eligible for benefits when one of the above criteria is met.

Procedure Codes

E0602

Accessories are considered eligible for benefits when the purchased breast pump is eligible for benefits.

Procedure Codes

A4281

A4282

A4283

A4284

A4285

A4286

When the above criteria are met, breast pumps meet the definition of DME and payment may be made for a breast pump according to the member's DME benefits.

The criteria above regarding an electric breast pump, a manual breast pump and accessories does not apply to those groups that follow the Women’s Health Federal Mandate effective August 1, 2012.

Procedure Codes

A4281

A4282

A4283

A4284

A4285

A4286

E0602

E0603

E0604

Quantity Level Limits for replacement equipment and supplies related to electric breast pumps:

PROCEDURE CODE

DEFINITION

QUANTITY LEVEL LIMIT APPLIED

A4281

Tubing for breast pump, replacement

2 times within 12 months from the breast pump date of service

A4282

Adapter for breast pump, replacement

2 times within 12 months from the breast pump date of service

A4283

Cap for breast pump bottle, replacement

2 times within 12 months from the breast pump date of service

A4284

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

2 times within 12 months from the breast pump date of service

A4285

Polycarbonate bottle for use with breast pump, replacement

2 times within 12 months from the breast pump date of service

A4286

Locking ring for breast pump, replacement

2 times within 12 months from the breast pump date of service

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

Links

References (PDF)

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Update on 2-25-2020 updated language

Internal Medical Policy Committee 3-17-2021 Coding update - Added A4281, A4282, A4283, A4284, A4285, A4286

Internal Medical Policy Committee 3-23-2022 Annual Review, no change in criteria

Internal Medical Policy Committee 3-23-2023 Annual Review, no change in criteria

Added Policy Application

Disclaimer

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Fargo, N.D., 58121

Medical Policies Quick Search

Electric Breast Pumps

Description:

Policy Application

Criteria

Procedure Codes

Procedure Code

Procedure Codes

Procedure Codes

Quantity Level Limits forreplacement equipment and supplies related to electric breast pumps:

PROCEDURE CODE

DEFINITION

QUANTITY LEVEL LIMIT APPLIED

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

Links

ND Committee Review

Disclaimer

Description

Policy Application

Criteria

Procedure Codes

Procedure Codes

Procedure Codes

Procedure Codes

Quantity Level Limits for replacement equipment and supplies related to electric breast pumps:

PROCEDURE CODE

DEFINITION

QUANTITY LEVEL LIMIT APPLIED

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

Links

ND Committee Review

Disclaimer