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MP 1.01.98

Breast Pump Rental


Medical Policy    
Section
Durable Medical Equipment
 
Original Policy Date

Last Review Status/Date
Local policy/11/09/2005

Issue
11:2005

Return to Medical Policy Index

 


Disclaimer

 

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Breast Milk has been demonstrated to be the safest and most effective food source for the premature infant.  It is the best tolerated form of enteral supplementation to the premature neonate.  It also provides passive immunity to infants which immunocomprimised by premature birth and Hydrocortisone therapy.

 


 

Policy

Blue Cross of Idaho Medical Quality Management Case Management department will review requests for the rental of Electric Breast Pump.  Criteria will be reviewed based on gestational age and medical necessity. 

If the determination is made to allow rental of electric breast pump, on a case by case basis, a contract exception letter will be drafted requiring specific dates of service and signature of policy holder. 

In the case of an ASC group, the group administrator will be contacted with the request.  The ASC group has the right to approve or disallow any recommendation by BCI in regards to contract exclusions.


Policy Guidelines

 

Rental will be considered for the following:

  1. Member who has given birth to an infant 34 wks gestational age or less and require NICU care.
  2. Member who has given birth to a 34 week to term infant, who is afflicted with medical conditions that would prevent the mother from breast feeding on site such a being intubated and ventilated for RDS, Hyaline Membrane Disease, or Pulmonary Hypertension.  In addition, if the mother must return to employment, which precludes ready access to breast milk for hospital feedings, the rental of a breast pump would be considered.
  3.  

Procedure:

  1. Preauthorization is required.
  2. Contract Limitations and Exclusions may apply.

Benefit Application

BlueCard/National Account Issues

No applicable information


Rationale

References:

University of Utah NBICU Orientation Manual Iowa Neonatology Handbook:  Enteral Feedings

Codes

Number

Description

HCPCS 

E0602

Breast pump, manual, any type

  E0603 Breast pump, electric (AC and/or DC), any type 
   E0604 Breast pump, heavy duty, hospital grade, piston operated, pulsatile vacuum suction/release cycles, vacuum regulator, supplies, transformer, electric (AC and/or DC) 
   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

Policy History
Date Action Reason
10/10/06 Add to Durable Medical Equipment section New policy