Mountain State Medical Policy Bulletin

Section: Durable Medical Equipment
Number: E-37
Topic: Breast Pumps
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Rental of an electric breast pump (E0603, E0604) is eligible for reimbursement when one of these criteria is met:


  1. 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.

  2. 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.

In lieu of an electric breast pump, purchase of a manual breast pump (E0602) is eligible for reimbursement when one of the above criteria is met.

Breast pumps 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. A participating, preferred or network provider can bill the member for the denied breast pump.

Coverage for durable medical equipment is determined according to individual or group customer benefits.

NOTE:
Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

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.


NOTE:
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.

Procedure Codes

A4281A4282A4283A4284A4285A4286
E0602E0603E0604   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Breast pumps (codes E0602, E0603, E0604) and related accessories (A4281-A4286) are not covered under any circumstances. A participating, preferred, or network provider can bill the member for the denied service.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

No Previous Versions

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary





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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.