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.

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.