Anthem Blue Cross Connecticut CG-DME-35 Electric Breast Pumps Form

This document addresses the use of standard electric breast pumps (non-hospital grade) or heavy-duty, hospital-grade breast pumps for initiating and maintaining expression of human breast milk in specified situations.

Clinical Indications

Medically Necessary:

A standard, non-hospital grade, electric breast pump is considered medically necessary when there is documentation of ongoing breastfeeding. 

An electric, heavy-duty, hospital-grade breast pump is considered medically necessary for any of the following indications:

1. When a breastfeeding infant is confined to the hospital; or
2. When a breastfeeding infant has a medical (for example, respiratory, cardiac or genetic condition) or congenital condition (for example, cleft palate) that interferes with breastfeeding; or
3. When the mother has been unsuccessful expressing sufficient breast milk after a trial using a manual, battery powered or standard electric pump.

Not Medically Necessary:

An electric breast pump (standard non-hospital grade or heavy-duty hospital grade) is considered not medically necessary in the absence of ongoing breastfeeding.

An electric, heavy-duty, hospital grade breast pump is considered not medically necessary when the criteria above are not met.