Point32 Commercial Clinical Policy

Point32 Breast Pumps Form

Effective Date

09/01/2023

Last Reviewed

07/19/2023

Original Document

  Reference



Breastfeeding is the physiological norm for both mothers and their children.

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 breastfed and/or receive expressed human milk exclusively for the first six months of life1.

There are three types of breast pumps:

  • Manual
  • Electric
  • Durable electric pumps also known as “hospital grade pumps”

Hospital grade breast pumps are considered to be a type of durable medical equipment (DME) and are not designed for commercial sale or use.

Clinical Guideline Coverage Criteria

The Plan may cover Manual, Electric and Hospital Grade Breast Pumps when medically necessary. The following are required for coverage for any type of Breast Pump:

  1. The pump must be obtained from a contracting Durable Medical Equipment (DME) provider
  2. The Member must have a physician’s prescription

Point32Health companies2121997Breast Pumps

Manual and Electric Breast Pumps

The Plan will cover the purchase of one breast pump, either manual or electric, for pregnant or postpartum Members, per pregnancy.

Hospital Grade Electric Breast Pumps

The Plan will cover the rental of one hospital grade breast pump for postpartum Members, in place of a manual or electric pump, when deemed appropriate by the ordering provider. Use of a Hospital Grade Breast Pump may be appropriate in the following circumstances:

  1. A premature hospitalized newborn/infant
  2. An infant with a congenital, or other, anomaly that interferes with the ability to breast feed effectively (e.g., cleft lip,cleft palate, and/or other anomalies of the tongue, mouth or pharynx)
  3. Mother is hospitalized and separated from the newborn/infant

NOTE: Hospital grade electric breast pump coverage may differ according to plan or products. Please refer to the member’s plan documents and the applicable Preventive Services documents: Harvard Pilgrim Health Care and Tufts Health Plan

Limitations

Coverage of breast pumps may vary depending on the terms of the Member's plan benefit document

Codes