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MP 1.01.98

Breast Pump Rental

Medical Policy    
Durable Medical Equipment 
Original Policy Date

Last Review Status/Date
Local policy/02/2015


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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.


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. 


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 medically necessary during the span that the infant is hospitalized under the following conditions:

  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.


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

Benefit Application

BlueCard/National Account Issues

No applicable information



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






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
ICD-10-CM (effective 10/1/15) Z39.1 Encounter for care and examination of lactating mother
  O92-O92.6 Other disorders of breast and disorders of lactation  associated with pregnancy and the puerperium

Policy History
Date Action Reason
10/10/06 Add to Durable Medical Equipment section New policy
2/2015 Replace local policy add clarification under med nec statement that services are considered only while infant is hospitalized


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