Coverage Policies

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Current policies effective through April 30, 2024.

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INDEX:



Effective Date: 08/01/2012	Title: Breast Pumps
Revision Date: 10/01/2016	Document: BI349:00
CPT Code(s): A4281-A4286, E0602-E0604
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. Manual breast pumps are covered with no member cost share when specific criteria are met. Electric breast pumps are covered as DME, subject to the annual DME limits and any required cost share; consult your plan documents.
Medical Statement
The following policy applies to new health plans and non-grandfathered plans that are currently subject to DHHS requirements for coverage of breast pumps, with coverage beginning in the first plan year that begins on or after August 1, 2012 (please check benefit plan descriptions): QualChoice considers purchase of a manual breast pump medically necessary for breastfeeding. This purchase is covered under the preventive medicine benefit without patient cost share. QualChoice considers the purchase of standard electric breast pump medically necessary durable medical equipment (DME) for initiation of breastfeeding. This purchase is covered under standard DME cost share and annual limits. QualChoice considers rental of an electrical breast pump medically necessary DME for the period of time that a newborn is detained in the hospital. For women using a breast pump from a prior pregnancy, a new set of breast pump supplies is considered medically necessary DME with each subsequent pregnancy for initiation or continuation of breastfeeding within the first 12 months following delivery. A replacement manual breast pump is considered medically necessary for subsequent pregnancies, for continuation of breastfeeding, for members who have not received either a standard electric breast pump or a manual breast pump within the previous three years. A replacement standard electrical breast pump is considered medically necessary DME for subsequent pregnancies, for initiation of breastfeeding in the postpartum period, for members who have not received a standard electric breast pump within the previous three years. QualChoice considers purchase of heavy duty electrical (hospital grade) breast pumps not medically necessary. Codes Used In This BI: A4281 Replacement breast pump tube A4282 Replacement breast pump adpt A4283 Replacement breast pump cap A4284 Replacement breast pump shield A4285 Replacement breast pump bottle A4286 Replacement breast pump lok ring E0602 Breast pump – manual any type E0603 Breast pump – electric any type E0604 Breast pump – heavy duty hospital grade
Limits
Rental or purchase of hospital grade breast pumps is not covered.
Reference
QualChoice: Breast Pumps. 2006. http://www.QualChoice.com/cpb/medical/data/400_499/0421.html (accessed 2-07) Anderson, J. W., et al: Breast-feeding and cognitive development: a meta-analysis. Am J Clin Nutr 70(4):525-35, 1999. Beaudry, M., et al: Relation between infant feeding and infections during the first six months of life. J Pediatr 126(2):191-7, 1995. Cigna Healthcare: Breast Pumps – (0046). Dewey, K., et al: Differences in morbidity between breast-fed and formula-fed infants. J Pediatr 126(5 Pt 1):696-702, 1995.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

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