Prior authorization request form Form

Pasteurized Donor Human Breast Milk (PDHM)
Last Review Date: October 10, 2025 Number: MG.MM.ME.71bC

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, (“EmblemHealth”) has adopted the herein policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Guideline Pasteurized Donor Human Breast Milk (PDHM) (which may include fortifiers as medically indicated) is considered medically necessary for infants who:  Have a documented birth weight of < 1500 grams (3.3 pounds); or  Have a congenital or acquired condition that places high risk of developing necrotizing enterocolitis (NEC) and/or infection

Coverage of PDHM* is for infants who meet the criteria above and one or more of the following conditions:  Medically or physically unable to receive maternal breast milk or participate in breast feeding; or  Unable to participate in breast feeding despite optimal lactation support; or  Born to mothers whose breast milk isn’t suitable for consumption due to the presence of certain substances or disease; or  In cases where the mother is medically or physically unable to produce maternal breast milk at all or insufficient quantities

• Outpatient coverage effective Jan. 1, 2025. Limitations/Exclusions An order for PDHM must be issued by a licensed medical practitioner for an infant who is medically or physically unable to receive maternal breast milk or participate in breast feeding or whose mother is medically or physically unable to produce maternal breast milk at all or in sufficient quantities or participate in breast feeding despite optimal lactation support

Applicable Procedure Code T2101 Human breast milk processing, storage and distribution only Revision History Nov. 8, 2024 Reinstated commensurate with New York State mandate which removes inpatient setting restriction. (Outpatient coverage eff. Jan. 1, 2025) Jul. 14, 2023 Retired policy Apr 12, 20218 Removed Medicaid-only restriction References New York State Insurance Law. https://nyassembly.gov/leg/?default_fld=%0D%0A&leg_video=&bn=s6674&term=&Summary=Y&Text=Y.