Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 05|01|2023 POLICY LAST UPDATED: 02|01|2023 OVERVIEW A breast pump is a mechanical device used to extract milk from the breast of a lactating individual. Breast pumps typically fall into three categories, manually operated, electric/battery powered and hospital grade electric.
This policy is applicable to hospital grade electric breast pumps.
For coverage of manual and non-hospital grade electric breast pumps, refer to the Preventive Services for Commercial Members in the Related Policies section below. Note: Hospital grade electric breast pumps are not covered/classified as part of preventive services. PRIOR AUTHORIZATION Not applicable MEDICAL CRITERIA Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercial Products A hospital grade electric breast pump is covered as a rental item only under the member’s durable medical equipment benefit level.
Blue Cross & Blue Shield of Rhode Island (BCBSRI) requires a licensed provider’s order for the initial sixty (60) days and for every additional sixty (60) day rental for a hospital grade breast pump. It is expected that the ordering provider will limit the order for the period of time which a hospital grade breast pump is necessary for the members use e.g. there is an involuntary separation of an infant from its mother for more than 24 hours due to illness or injury of the infant, a breast-feeding infant has a medical (for example, respiratory, cardiac or genetic condition) or congenital condition (for example, cleft palate) that interferes with breast-feeding or the breast feeder is having issues producing sufficient enough milk to effectively breastfeed with a non-hospital grade breast pump. Once a manual and/or non-hospital grade breast pump or non-breast pump feeding will meet the needs of the breast feeder and the baby, the order and necessity of a hospital grade breast pump will end.
BACKGROUND Breast-feeding is the physiological norm for both the parent and their child. Breast milk offers medical and psychological benefits not available from human milk substitutes. The American Academy of Family Physicians recommends that all babies, with rare exceptions, be breast-fed and/or receive expressed human milk exclusively for the first six months of life. Breast-feeding should continue with the addition of complementary foods throughout the second half of the first year. Breast-feeding beyond the first year offers considerable benefits to both mother and child and should continue as long as mutually desired. Hospital-grade electric breast pumps are specifically designed for reuse (sterilizable) and are not sold commercially.
Payment Policy | Breast Pumps – Hospital Grade

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

COVERAGE Medicare Advantage Plans and Commercial Products Benefits may vary between groups/contracts. Please refer to the Evidence of Coverage or Subscriber Agreement for applicable durable medical equipment, medical supplies, and prosthetic devices benefits/coverage.

CODING Medicare Advantage Plans and Commercial Products
The following HCPCS code(s) is covered: E0604RR Breast pump, Hospital grade, electric (AC and/or DC), any type

Note: Rental period is one month. Blue Cross & Blue Shield of Rhode Island’s standard rent-to-own policy for Durable Medical Equipment items (e.g. 10-month period) does not apply to hospital grade electric breast pumps.

RELATED POLICIES Durable Medical Equipment (DME)
Ordering Provider NPI Number Requirement Preventive Services for Commercial Members

PUBLISHED Provider Update, March 2023 Provider Update, July 2022 Provider Update, April 2022 Provider Update, April 2021 Provider Update, May 2020

REFERENCES Not applicable i

This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS