Breast Pumps - Excellus BlueCross BlueShield

Breast Pumps - Excellus BlueCross BlueShield

MEDICAL POLICY SUBJECT: BREAST PUMPS EFFECTIVE DATE: 01/23/03 REVISED DATE: 12/11/03, 12/02/04, 12/01/05, 12/07/06, 12/13/07, 02/28/13, 02/27/14, 04/...

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MEDICAL POLICY SUBJECT: BREAST PUMPS

EFFECTIVE DATE: 01/23/03 REVISED DATE: 12/11/03, 12/02/04, 12/01/05, 12/07/06, 12/13/07, 02/28/13, 02/27/14, 04/24/14 RE-ARCHIVED DATE: 04/23/15 EDITED DATE: 04/28/16 (ARCHIVED DATE: 12/11/08 EDITED DATE: 12/10/09, 12/09/10, 12/08/11, 04/27/17 POLICY NUMBER: 1.01.39 DELETED DATE: 10/25/12-02/28/13) CATEGORY: Equipment/ Supplies PAGE: 1 OF: 3  If a product excludes coverage for a service, it is not covered, and medical policy criteria do not apply.  If a commercial product, including an Essential Plan product, covers a specific service, medical policy criteria apply to the benefit.  If a Medicare product covers a specific service, and there is no national or local Medicare coverage decision for the service, medical policy criteria apply to the benefit. POLICY STATEMENT: I.

Personal manual or electric breast pumps are eligible for coverage when purchased from a participating DME provider.

II. Rental of heavy duty, hospital grade breast pumps are eligible for coverage during the period of time an infant is in the hospital. III. Replacement breast pumps are eligible for coverage: A. Manual - for each subsequent pregnancy; B. Electrical - for subsequent pregnancies when: 1. An electrical breast pump has not been purchased within 3 years; or 2. If the initial electrical breast pump is out of warranty and malfunctioning. IV. A new set of breast pump supplies are eligible for coverage with each subsequent pregnancy. V. For grandfathered groups: A. Manual breast pumps do not meet the definition of Durable Medical Equipment (DME) and are therefore considered ineligible for coverage. Manual breast pumps are used by healthy persons, do not require order or prescription by a physician, are unable to be reused by other patients, and are not treatment for an illness or injury. B. Electric breast pumps have been medically proven to be effective and are considered medically appropriate when a manual pump is ineffective (e.g., inability to express breast milk with the manual breast pump). C. Rental of heavy duty, hospital grade breast pumps are eligible for coverage during the period of time an infant is in the hospital. Refer to Corporate Medical Policy #1.01.00 regarding Durable Medical Equipment- Standard and Non-Standard. POLICY GUIDELINES: I.

Coverage for Durable Medical Equipment is contract dependent. Please refer to your Customer (Member/Provider) Service Department to determine contract coverage.

II. Coverage for comprehensive lactation support and counseling by a trained provider during pregnancy and/or in the postpartum period, and costs for the rental or purchase (depending on the terms of the contract) of breast feeding equipment will be provided without cost sharing as required by the Affordable Care Act (refer to Description section). III. A grandfathered plan or policy is generally a plan or policy that was in existence prior to 03/23/2010 that had at least one enrollee. Maintenance of grandfathered status after 03/23/2010 requires the plan or policy to limit the type of changes made to the terms of the plan or policy. Certain changes after 03/23/2010 will cause a loss of grandfathered status and would result in the plan or policy having to comply with several provisions under the Proprietary Information of Excellus Health Plan, Inc. A nonprofit independent licensee of the BlueCross BlueShield Association

SUBJECT: BREAST PUMPS

POLICY NUMBER: 1.01.39 CATEGORY: Equipment/ Supplies

EFFECTIVE DATE: 01/23/03 REVISED DATE: 12/11/03, 12/02/04, 12/01/05, 12/07/06, 12/13/07, 02/28/13, 02/27/14, 04/24/14 RE-ARCHIVED DATE: 04/23/15 EDITED DATE: 04/28/16 (ARCHIVED DATE: 12/11/08 EDITED DATE: 12/10/09, 12/09/10, 12/08/11, 04/27/17 DELETED DATE: 10/25/12-02/28/13) PAGE: 2 OF: 3

Affordable Care Act (e.g., coverage of breast pumps). If a plan or policy is grandfathered, there should be a statement in the plan or policy identifying the plan as a grandfathered plan. DESCRIPTION: A breast pump is a device used to express milk from the breast of a nursing mother. There are three types of breast pumps: I. Manual - operated manually by the individual; and II. Electric - alternating current/direct current (AC/DC) - (e.g., Lactina® Plus, Symphony®); single personal use due to inability to be properly sterilized between users; and III. Heavy-duty hospital grade, piston operated, pulsatile vacuum suction/release cycles, vacuum regulator (AC and/or DC, e.g., Hygeia EnDeare and Ameda Elite); able to be sterilized to allow for multiple users. According to the Preventive Services for Women portion of the Affordable Care Act, non-grandfathered group health plans are required to provide coverage without cost sharing for comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for the rental or purchase (depending on the terms of the contract) of breast feeding equipment. CODES:

Number

Description

Eligibility for reimbursement is based upon the benefits set forth in the member’s subscriber contract. CODES MAY NOT BE COVERED UNDER ALL CIRCUMSTANCES. PLEASE READ THE POLICY AND GUIDELINES STATEMENTS CAREFULLY. Codes may not be all inclusive as the AMA and CMS code updates may occur more frequently than policy updates. CPT:

No code(s) Copyright © 2017 American Medical Association, Chicago, IL

E0602

Breast pump manual, any type

E0603

Breast pump, electric (AC/DC), any type

E0604

Breast pump, hospital grade, electric (AC and/or DC), any type

A4281

Tubing for breast pump, replacement

A4282

Adapter for breast pump, replacement

A4283

Cap for breast pump bottle, replacement

A4284

Breast shield and splash protector for use with breast pump, replacement

A4285

Polycarbonate bottle for use with breast pump, replacement

A4286

Locking ring for breast pump, replacement

ICD9:

V24.1

Lactating mother

ICD10:

Z39.1

Encounter for care and examination of lactating mother

HCPCS:

Proprietary Information of Excellus Health Plan, Inc.

SUBJECT: BREAST PUMPS

POLICY NUMBER: 1.01.39 CATEGORY: Equipment/ Supplies

EFFECTIVE DATE: 01/23/03 REVISED DATE: 12/11/03, 12/02/04, 12/01/05, 12/07/06, 12/13/07, 02/28/13, 02/27/14, 04/24/14 RE-ARCHIVED DATE: 04/23/15 EDITED DATE: 04/28/16 (ARCHIVED DATE: 12/11/08 EDITED DATE: 12/10/09, 12/09/10, 12/08/11, 04/27/17 DELETED DATE: 10/25/12-02/28/13) PAGE: 3 OF: 3

REFERENCES: *Academy of Breastfeeding Medicine. Guidelines for hospital discharge of the breastfeeding term newborn and mother: “Going home protocol”. ABM protocol. 2007 [http://www.bfmed.org/Media/Files/Protocols/protocol_2goinghome_revised07.pdf] accessed 3/14/17. *American Academy of Pediatrics. Policy statement: breastfeeding and the use of human milk. Ped 2012 Mar 1;129(8):e827-e841 [http://pediatrics.aappublications.org/content/129/3/e827.short] accessed 3/14/17. Federal Patient Protection and Affordable Care Act, Section 2713. *Fewtrell M, et al. Randomized study comparing efficacy of novel manual breast pump with mini-electric breast pump in mothers of term infants. J Hum Lact 2001 May:17(2):126-31. *Fewtrell M, et al. Randomized trial comparing the efficacy of novel manual breast pump with standard electric breast pump in mothers who delivered preterm infants. Ped 2001 Jun;107(6):1291-7. U.S. Food and Drug Administration. Home health and consumer devices. Breast pumps. 2013 Jan 16. Last updated 05/16/16.[http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerPro ducts/BreastPumps/default.htm] accessed 3/14/17. *key article KEY WORDS: Breast pump.

CMS COVERAGE FOR MEDICARE PRODUCT MEMBERS There is currently no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for the use of Breast pumps.

Proprietary Information of Excellus Health Plan, Inc. By A11y Updated at 1:24 pm, Mar 16, 2018