Electric Breast Pumps

Section: Durable Medical Equipment
Effective Date: May 01, 2020
Revised Date: February 25, 2020
Last Reviewed: March 16, 2020

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.

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.

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

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Update on 2-25-2020 updated language

Disclaimer

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect BCBSND’s reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.