Subject:
Breast Pumps
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Breast pumps are devices used by breastfeeding women to extract or express their breast milk. The devices may be hand-(manual), battery-, or electrically-operated. Electric breast pumps are more efficient than manual breast pumps. Manual and electric breast pumps that are available commercially are not designed for reuse, and are most commonly sold to mothers with normal infants who are working, traveling, or for other reasons not always home to breastfeed the baby. Heavy duty electrical (hospital grade) breast pumps are recommended and typically used during an extended separation of mother and infant due to hospitalization caused by illness or prematurity. A hospital-grade breast pump is the most effective pump, especially when used with a double pump kit, which allows for pumping of both breasts at once.
Manual pumps are considered Class I medical devices, requiring manufacturers to register the device with the FDA. Powered breast pumps are considered Class II medical devices, requiring manufacturers to submit a premarket 510(k) notification to the FDA.
Human milk is species-specific and all substitute feeding preparations differ markedly from it, making human milk uniquely superior for infant feeding. Human breast milk is widely acknowledged as the gold standard for infant nutrition. Breastfeeding has many health benefits to both the mother and the baby. Breastfed babies have fewer ear and respiratory infections, allergies, gastrointestinal diseases, SIDS, lymphoma and Type 1 diabetes. Preterm infants who receive breast milk have been reported to experience greatly reduced rates of sepsis and necrotizing enterocolitis compared to infants who receive milk substitutes. Mothers who breastfeed have quicker return to pre-pregnancy uterine size with less bleeding, decreased risk of breast and ovarian cancer and osteoporosis.
Policy:
(NOTE: The Women's Preventive Services provision of the Affordable Care Act (ACA) requires health plans to cover breastfeeding support, supplies, and counseling including manual and standard electric breast pumps. It does not include heavy duty or hospital grade electrical breast pump. Also note that the mandate does not pertain to grandfathered health plans.
Pursuant to the New Jersey State Mandate on Breast Feeding Support Law (P.L. 2019, c.343 Effective July 11, 2020), health benefit plans are required to provide coverage for expenses incurred in the rental or purchase of a double electric or manual single-user breast pump, multi-user breast pump, purchase of two breast pump kits, appropriate size breast pump flanges, or other lactation accessories recommended by a health care provider. ASO/ASC/Self-Insured/Self-Funded Groups are exempt from these State mandated requirements but may choose to include these benefits at their discretion. For those self-insured accounts which opted not to adopt the mandate, the medical necessity criteria as specified below must be applied.
NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. Coverage for breast pumps is subject to the terms, conditions and limitations of the member's contract.
II. For those groups covered by the mandate(s), as noted above, the rental or purchase of a single user (manual or electric) breast pump or multi-user breast pump is considered medically necessary.
III. For those groups NOT covered by the mandate, the following criteria apply:
A. A manual or electric single use breast pump (E0602 or E0603) is medically necessary for women who intend to breast feed after delivery.
B. A manual or electric single use breast pump (E0602 or E0603) is medically necessary for women who plan to breast feed an adopted infant.
C. A hospital grade electrical breast pump (E0604) is medically necessary when any of the following conditions are met:
1. The infant and mother are separated due to hospitalization and direct breast feeding is not possible.
2. The infant has a congenital disorder (e.g., cleft lip/palate) that interferes with breast feeding.
3. The infant has a cardiac anomaly or any other medical condition that makes him/her unable to sustain breastfeeding due to poor coordination of suck and swallow or fatigue.
4. The mother has an anatomical breast problem (e.g., inverted nipple), which may resolve with the use of a breast pump.
D. A heavy duty breast pump is not considered medically necessary when none of the above listed conditions are present.
Medicare Coverage:
There is no National Coverage Determination (NCD) for Breast Pumps. In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.
Medicaid Coverage:
The (State/Federal) Mandate indicated above applies. Please note that an executive State order extended the effective date for the breast pump mandate to 01/01/2021.
FIDE-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Breast Pumps
References:
1. American Academy of Pediatrics (AAP). Breastfeeding and the Use of Human Milk. Pediatrics. 2012 March 1; 129(3):e827-e841)
2. American Academy of Family Physicians (AAFP). Breastfeeding, Family Physicians Supporting (Position Paper). (2001, 2008, 2014) Last accessed 05/09/2017. Available at: http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html
3. Reilly S et al; Academy of Breastfeeding Medicine Clinical Protocol Committee. ABM Clinical Protocol #17: Guidelines for breastfeeding infants with cleft lip, cleft palate, or cleft lip and palate. Breastfeed Med. 2007 Dec;2(4):243-50.
4. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Adv Exp Med Biol. 2004;554:63-77.
5. Henderson G, Fahey T, McGuire W. Nutrient-enriched formula versus human breast milk for preterm infants following hospital discharge. Cochrane Database Syst Rev. 2004 Oct 17;(4):CD004862.
6. Bekcer GE, McCormick FM, Refrew MJ. Methods of milk expression for lactating women. Cochrane Database Syst Rev. 2015;CD006170.
7. Johns HM, Forster DA, Amir LH, et al. Prevalence and outcomes of breast milk expressing in women with healthy term infants: a systematic review. BMC Pregnancy Childbirth 2013 Nov 19;13:212.
8. Abrams SA, Hurst NM. Breast milk expression for the preterm infant. In: UpToDate, Gracia-Prats J, Hoppin AG (Eds), UpToDate, Waltham, MA. (Accessed on May 9, 2017.)
9. Qi Y, Zhang Y, Fein S, et al. Maternal and breast pump factors associated with breast pump problems and injuries. J Hum Lact. 2014;30(1):62-72.
10. Enger L, Hurst N, Patient education: Pumping breast milk (Beyond the Basics). Abrams s, Hoppin A (Eds). Up to Date, Waltham MA (Accessed on April 29, 2020.)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
E0602
E0603
E0604
A4281
A4282
A4283
A0284
A4285
A4286
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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