Breast Pumps - Manual and Electric (CG002) Form

The plan members who are pregnant or have recently delivered or adopted an infant are eligible to receive a breast pump to assist with the expression of breast milk for the purpose of infant nutrition. The use of breast pumps to assist with nursing has expanded in the last decade worldwide as both a medical adjunct to support milk let-down (output), and as a tool to accommodate working mothers both in and outside the home. Human milk contains the optimal mix of nutrients for most newborn infants, with the exception of some infants with specific medical conditions. Long- and short-term benefits to the lactating (breastfeeding) mother and to the newborn infant are well documented in the medical literature. Medical professionals around the world recommend exclusive breastfeeding for the first six months of life in most instances; among these are the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), the World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC). More specifically, AAP recommends the continuation of breastfeeding with complimentary foods for 2 years or more. In addition to medical benefits, human breast milk is a convenient source of infant nutrition as it does not require mixing and warming. Additionally, it is free and can save hundreds of dollars of formula costs per month. Maternal health benefits have also been linked to breast feeding. Studies have found that breastfeeding for greater than twelve months is associated with decreased incidence of maternal diabetes, hypertension, breast cancer, and ovarian cancer. In order to prevent HIV transmission, breastfeeding is not recommended for mothers infected with HIV. For suspected or confirmed COVID-19 1 mothers, ACOG’s current stance is that there is no contraindication for breastfeeding as the majority of data has not demonstrated SARS-CoV-2 virus transmission in breastmilk. The purchase or rental of a breast pump must be obtained through an in-network Durable Medical Equipment (DME) provider. A prescription from a health-care provider (physician, nurse practitioner, midwife, or lactation consultant) may be required by some DME providers. Definitions “Breast Pumps” are mechanical devices used by lactating mothers to initiate and maintain expression of human breast milk. The rising awareness of the benefits of breastfeeding has driven growth in the breast pump market, which now offers a large array of breast pump models and types. The plan recognizes three types of breast pumps, which are the most commonly identified in retail and medical venues:

1. “Manual Breast Pumps” are non-powered devices designed to express breast milk using suction which is created through a manual process. This type of pump is lightweight, portable, inexpensive, and very easy to handle. The manual breast pump is intended for one user only. Manual breast pumps are sold by lactation and DME providers as well as in some retail stores. Manual breast pumps should not be shared because of the risk of infection transmission across multiple users.
2. “Standard Electric Breast Pumps” contain an electric or battery-powered suction device that creates pulsating suction that mimics infant use. These pumps may be labeled as “single” or “double,” referencing the ability to pump a single breast or both breasts at the same time. Some electric pumps may have a battery pack to aid pumping when an electric outlet is not available. Standard electric breast pumps are intended for one user only. Standard electric breast pumps are sold by lactation and DME providers as well as in some retail stores. Standard electric breast pumps should not be shared because of the risk of infection transmission across multiple users.
3. “Hospital-Grade, Heavy-Duty Electric Breast Pumps” are recommended for use in specific medical conditions in mother and infant. These breast pumps are approved for reuse, as they may be sterilized between users. Hospital-grade breast pumps are rented for use to a medically eligible lactating woman and are usually leased by a hospital. Hospital-grade, heavy-duty breast pumps are not available for purchase commercially. Note: The term “hospital-grade breast pump” has taken on commercial use as breast pump makers have improved the strength and quality of commercially available pumps. The term is not recognized by the FDA and does not indicate that a pump is used in or by hospitals. Pumps available for sale on the open market have little regulation as to their label and there is no consistent quality standard for this classification. 2 Clinical Indications General Clinical Indications Breast pump are medically necessary when ONE of the following criteria are met:
4. A Plan member who is in the third trimester of pregnancy and desires to breastfeed after delivery; or
5. A Plan member who has recently delivered an infant and desires to breastfeed; or
6. A female Plan member who has recently adopted an infant and intends to induce lactation under the guidance of a healthcare professional. Manual Breast Pumps or Standard Electric Breast Pumps Manual breast pumps and standard electric breast pumps are single user devices and do not require prior authorization to determine medical necessity. Manual breast pumps and standard electric breast pumps are eligible for reimbursement when ALL of the following criteria are met:
7. One of the criteria in General Clinical Indications (above) are met; and
8. A clearly delineated prescription for a health care provider (e.g., DME vendor) is provided when required. Members may request the selected device during the last trimester of pregnancy and the post-partum period. Hospital-Grade, Heavy-Duty Breast Pumps “Hospital Grade” breast pumps are available for rental when ALL of the following criteria are met:
9. General clinical indications (above) are met; and
10. Prescription from a healthcare provider (physician, nurse practitioner, midwife, or lactation consultant) indicating the medical benefit to mother or infant; and
11. Documentation of medical necessity by a health-care provider indicating 1 or more of the following: a. NICU admission or prolonged hospitalization of the delivered infant(s); or b. Multiple births in which a health care provider has determined that a standard electric pump would not be beneficial; or c. Premature birth(s) in which a health care provider has determined that a standard electric pump would not be beneficial; or Infants with oral anomalies (i.e., cleft palate); or Infants with developmental delay (i.e., genetic syndromes); or Infants with difficulty establishing maternal milk supply; or d. e. f. g. Maternal conditions such as mastitis in which a health care provider has determined that a standard electric pump would not be beneficial. 3 In most cases, medical necessity for a hospital grade breast pump can only be established following delivery. However, in instances where a congenital anomaly or other condition is identified prior to delivery, a provider can request the device for a member during the last-trimester of their pregnancy. Adoption It is recommended that adoptive mothers who intend to breastfeed request and begin using, under the guidance of a licensed practitioner, a selected breast pump device at least two months prior to the date they anticipate beginning breastfeeding. In most circumstances, either a manual or standard electric breast pump may be considered. Medically Necessary Accessories A breast pump rental or purchase includes medically necessary accessories for the pump to operate. This includes: standard power adaptor (if electric), tubing adaptors, tubing, locking rings, bottles specific to breast pump operation, caps for bottles that are specific to the breast pump, valves, filters, and breast shield and/or splash protector for use with the breast pump. Experimental or Investigational / Not Medically Necessary The following items are considered comfort or convenience items, are available over-the-counter, or are considered not medically necessary: ● Baby weight scales ● Batteries, battery-powered adaptors, and battery packs ● Bottles which are not specific to breast pump operation including the associated bottle nipples, caps and lids ● Breast milk storage bags, ice-packs, labels, labeling lids, and other similar products ● Breast pump cleaning supplies including soap, sprays, wipes, steam cleaning bags and other similar products ● Creams, ointments, and other products that relieve breasts or nipples ● Electrical power adapters for travel ● Garments or other products that allow hands-free pump operation ● More than 1 pump per pregnancy (unless pump damage/failure or the particular type of pump the mother currently has is not effective for retrieving breast milk): ○ Only one pump per pregnancy is considered medically necessary for the duration of breastfeeding. ○ In the case of a pregnancy resulting in multiple births, only one breast pump is considered medically necessary per pregnancy. ● Nursing bras, bra pads, breast shells, nipple shields, and other similar products ● Travel bags, and other similar travel or carrying accessories