MP-04 Breast Pump Form

Medical Policy
Breast Pump
Page 1

Current Effective Date: 01/01/2019
Original Effective Date: 01/20/2014
Next Review/Revision Date: 01/01/2020
Plans: QUEST Integration (Medicaid)

I. Definition
Breast feeding provides the best nutrition for infants, and health benefits for the mother. A breast pump may assist mothers who have difficulty breastfeeding, or for those whose infants have health conditions. Many mothers prefer to purchase an electric breast pump, instead of a manual breast pump. Researchers and specialists recommend electric breast pumps because they may be more efficient than manual breast pumps.

II. Criteria
A. AlohaCare covers one standard electric breast pump per pregnancy when members meet one of the following criteria:

1. Breast conditions, like engorgement, infection, breast abscess, or fibrocystic breasts;
2. Nipple conditions, like itching, bleeding, pain or fissures of nipples;
3. Supplementation for low milk supply, or any lactation risk factors;
4. Expressing milk after delivering a stillborn infant;
5. Need to go to work or school;
6. Any other reason which prevents or limits breastfeeding;
7. Having normal pregnancy and/or health baby.
   Or infants:

Medical Policy
Breast Pump
Page 2

8. Having difficulty latching‐on or difficulty feeding at the breast; 9. Having genetic, neurologic, or other medical conditions;

9. That are premature.

   B. Members can request for breast pumps at any time during the 3rd trimester (29‐40 weeks) of their pregnancy or postpartum.

   III. Guidelines
   Prior Authorization is not required.

   IV. Limitations

10. The replacement of breast pumps and supplies are not covered. If the breast pump is broken while under warranty, members need to contact the manufacturer or the supplier.

    V. Coding Information

    The following medical codes are relevant codes for diagnosis and procedures for breast pump and for informational purposes only. All the medical codes listed in this policy do not constitute or imply benefit coverage or provider reimbursement.
    ICD‐10‐CM
    Description
    Z33.1
    Pregnant state, incidental
    OØ9. 03
    Supervision of pregnancy with history of infertility, third trimester
    OØ9. 13
    Supervision of pregnancy with history of ectopic or molar pregnancy, third trimester
    OØ9. 213
    Supervision of pregnancy with history of pre‐term labor, third trimester

Medical Policy
Breast Pump
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OØ9. 293
Supervision of pregnancy with other poor reproductive or obstetric history, third trimester
OØ9. 33
Supervision of pregnancy with insufficient antenatal care, third trimester
OØ9. 43
Supervision of pregnancy with grand multiparity, third trimester
OØ9. 523
Supervision of elderly multigravida, third trimester
OØ9. 613
Supervision of young primigravida, third trimester
OØ9. 623
Supervision of young multigravida, third trimester
OØ9. 73
Supervision of high risk pregnancy due to social problems, third trimester
OØ9. 813
Supervision of pregnancy resulting from assisted reproductive technology, third trimester
OØ9. 823
Supervision of pregnancy with history of in utero procedure during previous pregnancy, third trimester
OØ9. 893
Supervision of other high risk pregnancies, third trimester
OØ9.93
Supervision of high risk pregnancy, unspecified, third trimester
O36.8ØX1‐ O36.8ØX9
Other congenital malformations of esophagus
Z39.Ø
Encounter for care and examination of mother immediately after delivery
Z39.1
Encounter for care and examination of lactating mother
Z39.2
Encounter for routine postpartum follow‐up
Q35.1‐Q35.7 Cleft palate
Q36.Ø
Cleft lip, bilateral
Q36.1
Cleft lip, median
Q36.9
Cleft lip, unilateral
Q37.0‐Q37.7 Cleft hard palate with bilateral cleft lip

Medical Policy
Breast Pump
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Q38.0
Congenital malformations of lips, not elsewhere classified
Q38.1
Ankyloglossia
Q38.2
Macroglossia
Q38.3
Other congenital malformations of tongue
Q38.4
Congenital malformations of salivary glands and ducts
Q38.6
Other congenital malformations of mouth
Q38.7
Congenital pharyngeal pouch
Q38.8
Other congenital malformations of pharynx

HCPCS
Description
E0603
Breast pump, electric (AC and/or DC), any type

IV.
References/Resources

Document Name
Effective Date
Source
Optimizing Support for Breastfeeding as Part of Obstetric Practice
October 2018 ACOG Committee Opinion Number 756, October
2018https://www.acog.org/Clinical-Guidance-and- Publications/Committee-Opinions/Committee-on- Obstetric-Practice/Optimizing-Support-for- Breastfeeding-as-Part-of-Obstetric-Practice
Breastfeeding in Underserved
Women: Increasing Initiation and
Continuation of Breastfeeding
2018
ACOG Committee Opinion Number 570, Reaffirmed
2018, https://www.acog.org/Clinical-Guidance-and- Publications/Committee-Opinions/Committee-on- Health-Care-for-Underserved-Women/Breastfeeding-in- Underserved-Women-Increasing-Initiation-and-

Medical Policy
Breast Pump
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Continuation-of-Breastfeeding
Methods of milk expression for lactating women
2016
Cochrane Database Syst Rev. 2016 Sep 29; 9:CD006170.
Epub 2016 Sep 29.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14 651858.CD006170.pub5/full

Breast pumps as an incentive for breastfeeding: a mixed methods study of acceptability
2016
; Crossland N, Thomson G, Morgan H, MacLennan G, Campbell M, Dykes F, Hoddinott P., Matern Child Nutr.
2016 Oct;12(4):726-39. doi: 10.1111/mcn.12346. Epub
2016 Aug 9
https://www.ncbi.nlm.nih.gov/pubmed/27502101
Pregnancy‐related Services
2014
Request For Proposal
Med‐QUEST Division (MQD) Program and Services
“Women’s Preventive Services
Guidelines”
08/01/2012
HRSA (Health Resources and Services Administration) http://www.hrsa.gov/womensguidelines/
“Fact Sheet: Women’s Preventive Services and Religious Institutions”
02/10/2012
The White House Office of the Press Secretary http://www.whitehouse.gov/the‐press‐ office/2012/02/10/fact‐sheet‐women‐s‐preventive‐ services‐and‐religious‐institutions
“The Quiet Revolution:
Breastfeeding Transformed With the Use of Breast Pumps”
01/31/2011
Kathleen M. Rasmussen, and Sheela R. Geraghty. American Journal of Public Health
http://ajph.aphapublications.org/doi/full/10.2105/AJP H.2011.300136
“Development of a WIC Single‐ User
Electric Breast Pump Protocol”
02/20/2011
Alena Clark, Jennifer Dellaport. Breast Pump Medicine http://online.liebertpub.com/doi/pdf/10.1089/bfm.20 10.0012
“Pumping Your Breast Milk”
09/2013
Baby Center Medical Advisory Board
http://www.breastpumps.com/15_reasons_to_use_a_ breast_pump

Medical Policy
Breast Pump
Page 6

“Why You Need a Breast Pump”

Susie Hamilton. Breast Pump Direct Product Expert http://www.breastpumpsdirect.com/whyyou_need_ br eastpump_a/133.htm

Review/Revision History

A. 12/01/2014, added a breast pump supplier in the “Limitation”.
B. 03/23/2015, deleted the list of vendors.
C. 03/23/2016, corrected line of business; updated the references.
D. 09/01/2017, reviewed the policy.
E. 01/01/2019, removed prior authorization; updated the references. F. 01/01/2020 , Retired