Breast Pumps - Premier Health Plan

Breast Pumps - Premier Health Plan

Premier Health Plan POLICY AND PROCEDURE MANUAL Policy Number: MP.053.PH Last Review Date: 11/12/2015 Effective Date: 01/01/2016 Renewal Date: 01/01/2...

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Premier Health Plan POLICY AND PROCEDURE MANUAL Policy Number: MP.053.PH Last Review Date: 11/12/2015 Effective Date: 01/01/2016 Renewal Date: 01/01/2017

MP.053.PH - Breast Pumps This policy applies to the following lines of business:  Premier Commercial  Premier Employee

Premier Health Plan considers Breast Pumps medically necessary for the following indications: A standard electric breast pump is considered medically necessary for any one of the following indications: Infant 1. The infant is detained in the hospital (prolonged infant hospitalization) and the mother is discharged; Or 2. The infant has a congenital anomaly that interferes with its ability to feed (e.g., Down Syndrome, cleft lip or palate, cardiac anomaly, Pierre-Robin syndrome); Or 3. The infant has neurological problems (e.g., facial palsy, cerebral palsy, oral-motor dysfunction); Or 4. The infant is unable to initiate breast-feeding due to a medical condition (e.g., prematurity, oral defect); Or 5. Prematurity – less than 37 weeks gestation; Or 6. Low birth weight – less than 2500 grams; Or 7. Failure to thrive. OR Maternal (To prevent discomfort from breast engorgement): 1. Temporary weaning (i.e., direct breast feeding is not possible due to mother/infant separation, or mother is required to take a medication or undergo a diagnostic test that is contraindicated with breast feeding); Or 2. Multiple gestation delivery;

MP.053.PH - Breast Pumps Policy Number: MP.053.PH Last Review Date: 11/12/2015 Effective Date: 01/01/2016 Renewal Date: 01/01/2017 Or 3. Temporary drug therapy which contraindicates breast feeding; Or 4. Maternal illness or condition requiring hospitalization; Or 5. Breast feeding mothers who will be separated from their baby for reasons of work, school, or sickness. The treating physician should furnish the reason the mother and baby will be separated. Limitations 1. Breast pumps must be obtained from a Durable Medical Equipment (DME) provider. 2. Not covered - Heavy duty hospital grade breast pumps are considered institutional equipment. DME that is considered institutional grade is not appropriate for use in the home. 3. Breast feeding is contraindicated in all of the following situations:  Infants with classic galactosemia (galactose 1-phosphate uridyltransferase deficiency),  Mothers who have active untreated tuberculosis disease or are human T-cell lymphotropic virus type I–or II–positive,  Mothers who are receiving diagnostic or therapeutic radioactive isotopes or have had exposure to radioactive materials (for as long as there is radioactivity in the milk),  Mothers who are receiving antimetabolites or chemotherapeutic agents or a small number of other medications until they clear the milk,  Mothers who are using drugs of abuse ("street drugs"); Mothers who have herpes simplex lesions on a breast (infant may feed from other breast if clear of lesions). Background A breast pump is a device used to extract milk from the breast of a lactating mother for purposes of feeding an infant when the mother is unable to be present at feeding time or when the infant is unable to breastfeed due to congenital anomalies; poor or weak sucking response or other medical condition of the infant or lactating mother that interferes with normal feeding. All breast pumps consist of three basic parts: the breast shield, the pump, and the milk container. There are three types of breast pumps: 1. Manual Breast Pumps - operated manually by the individual. They are used by healthy persons, do not require a physician’s order or prescription, and can be obtained over the counter. Page 2 of 5

MP.053.PH - Breast Pumps Policy Number: MP.053.PH Last Review Date: 11/12/2015 Effective Date: 01/01/2016 Renewal Date: 01/01/2017 2. Standard Electric Breast Pumps - alternating current/direct current (AC/DC) standard electric breast pumps are proven to be effective and medically appropriate when injury or illness of the mother or infant prevents normal breast feeding and a manual pump is not effective. An electric breast pump is used to extract milk from a lactating mother’s breast for infant feeding when the infant is too sick or too weak to suck or when the mother cannot be present at feeding time. An electric breast pump is more effective than a manual pump in effectively emptying the breast of milk for the majority of women. 3. Heavy Duty Hospital Grade Breast Pumps (e.g., Lactina®, Synphony®) - piston operated pulsatile vacuum suction / release with a vacuum regulator (AC and/or DC). These pumps are institutional grade for use in the hospital as specified by the manufacturer.

Codes: CPT Codes / HCPCS Codes / ICD-10 Codes Code

Description

HCPCS codes covered if selection criteria are met (If Appropriate): E0602

Breast Pump, manual, any type

E0603

Breast pump, 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

HCPCS codes covered for inpatient hospital setting: E0604

Breast pump, heavy duty, hospital grade, piston operated, pulsatile vacuum suction/release cycles, vacuum regulator, supplies, transformer, electric (AC and/or DC)

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MP.053.PH - Breast Pumps Policy Number: MP.053.PH Last Review Date: 11/12/2015 Effective Date: 01/01/2016 Renewal Date: 01/01/2017 References 1. Academy of Breastfeeding Medicine. Protocol #12 – Transitioning the Breastfeeding/Breastmilk-fed Premature Infant from the Neonatal Intensive Care Unit to Home. Dated: 9/17/2004. Available at: http://www.bfmed.org/Media/Files/Protocols/Protocol_12.pdf 2. American Academy of Pediatrics. Policy statement: Breastfeeding and the use of human milk. Pediatrics 2012 Feb; 129(3):e827-e841. http://pediatrics.aappublications.org/content/129/3/e827.full.pdf+html. 3. Becker GE, Cooney F, Smith HA. Methods of milk expression for lactating women. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD006170. doi: 10.1002/14651858.CD006170.pub3. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006170.pub3/pdf 4. Department of Health and Human Services. Agency for Healthcare Research and Quality. (AHRQ). National Guideline Clearinghouse (NGC). Moel Breastfeeding Policy. NGC #8015. Last Updated: Oct. 19, 2010. http://www.guideline.gov/content.aspx?id=24013&search=breastfeeding 5. FDA. Types of Breast Pumps. Last updated 09/25/2013. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealth andConsumer/ConsumerProducts/BreastPumps/ucm061584.htm 6. Moretti M. Breastfeeding and Drugs. Drugs usually contraindicated while breastfeeding. MotherRisk.org (The Hospital for Sick Children – Toronto). Accessed: June 24, 2014. http://www.motherisk.org/women/breastfeeding.jsp;jsessionid=CCEA69278C273 ECB8738EE3307D9BA27 7. 5160-10-25 Lactation Pumps. http://codes.ohio.gov/oac/5160-10-25 8. U.S. Department of Health & Human Services. Health Resources and Service Administration (HRSA). Women's Preventive Services Guidelines. Affordable Care Act Expands Prevention Coverage for Women’s Health and Well-Being. Accessed: June 24, 2014. Available at: http://www.hrsa.gov/womensguidelines/ Disclaimer: Premier Health Plan medical payment and prior authorization policies do not constitute medical advice and are not intended to govern or otherwise influence the practice of medicine. The policies constitute only the reimbursement and coverage guidelines of Premier Health Plan and its affiliated managed care entities. Coverage for services varies for individual members in accordance with the terms and conditions of applicable Certificates of Coverage, Summary Plan Descriptions, or contracts with governing regulatory agencies. Premier Health Plan reserves the right to review and update the medical payment and prior authorization guidelines in its sole discretion. Notice of such changes, if necessary, Page 4 of 5

MP.053.PH - Breast Pumps Policy Number: MP.053.PH Last Review Date: 11/12/2015 Effective Date: 01/01/2016 Renewal Date: 01/01/2017 shall be provided in accordance with the terms and conditions of provider agreements and any applicable laws or regulations. These policies are the proprietary information of Evolent Health. Any sale, copying, or dissemination of said policies is prohibited.

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