OAR 410-122-0250: Breast Pumps

(1) Indications and limitations of coverage and medical appropriateness: (a) In accordance with Prioritized List of Health Services Breastfeeding Support and Supplies Guideline Note, the Division may cover a breast pump and supplies for postpartum women when a pump is necessary to establish or maintain milk production in order to maximize availability of breast milk to the baby; (b) For cases in which there is a medical indication for breast pumps, the pumps shall be supplied whenever possible within 24 hours to allow for continued milk production; (c) The client or caregiver shall receive instruction from the supplier in the proper use and care of the breast pump within 48 hours of receiving the equipment; (d) The rental of a hospital grade breast pump (E0604) may be covered for up to three (3) months when prescribed for use in the home; (e) A breast pump shall not be provided until a need is determined following birth; (f) A breast pump shall not be provided if it is known that mother is using a substance that is contraindicated while breastfeeding and does not plan to stop its use; (g) Replacement supplies may be covered when medically necessary and for the continued operation of the breast pump (E0602, E0603, E0604); (A) Reimbursement of medically necessary replacement supplies are limited to replacement tubing, replacement adapter, replacement cap for breast pump bottle, replacement breast shield and protector, replacement polycarbonate bottle, replacement locking ring, replacement valve, and a disposable collection and storage bag for breast milk (any size, any type); (B) The following represents the usual number of supplies expected to be medically appropriate; however, the quantity and frequency of replacement supplies shall be determined by the treating practitioner: (i) A4281 – 2 units per year; (ii) A4282 – 2 units per year; (iii) A4283 – 2 units per year; (iv) A4284 – 2 sets per year; (v) A4285 – 2 units per year; (vi) A4286 – 2 units per year; (vii) A4287 – 186 units per month; (viii) A4288 – 2 units per year. (2) Prior Authorization (PA): A PA is obtained from the same authorizing authority as specified in OAR 410-122-0040. PA is required for the following: (a) Replacement of the breast pump due to loss, theft, or irreparable damage in accordance with OAR 410-122-0184; (b) Replacement supplies not identified in this rule; (c) Rental of a hospital grade breast pump (E0604) beyond the third month; (3) The following services are not considered medically necessary: (a) Accessories not necessary for the operation of a breast pump (for example, travel bags, nursing bras, bra pads, breast feeding pillows, etc.); (b) An electric breast pump for the comfort and convenience of the mother; (c) Purchase of heavy-duty hospital grade breast pumps; (d) Replacement parts covered under the manufacturer’s and/or supplier’s warranty. (4) Reimbursement: (a) Reimbursement for the purchase of a single-user electric breast pump (E0603) includes all parts and supplies necessary for the operation of the electric pump; (b) Reimbursement for the purchase of a manual breast pump (E0602) includes all parts and supplies necessary for the operation of the manual pump; (c) Reimbursement for the first month’s rental of a hospital grade breast pump (E0604) includes all parts and supplies necessary for the operation of the hospital grade pump; (d) Replacement supplies, other than breast shields, are not reimbursable at the time of purchase or rental; (e) Rental charges apply to purchase; (f) Reimbursement is limited to the purchase of one (1) breast pump per pregnancy; (5) Documentation: (a) For services requiring prior authorization, submit documentation that supports coverage criteria in this rule are met; (b) Medical records and documentation to support the client meets criteria and conditions of coverage in this rule must be on file with the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and made available to the Division on request. (6) Procedure Codes: (a) E0602 — Breast pump, manual, any type — purchase only; (b) E0603 — Breast pump, electric (AC and/or DC), any type — purchase only; (c) E0604 — Breast pump, hospital grade, electric (AC and/or DC), any type — rental only; (d) A4281 — Tubing for breast pump, replacement; (e) A4282 — Adapter for breast pump, replacement; (f) A4283 — Cap for breast pump bottle, replacement; (g) A4284 — Breast shield and splash protector for use with breast pump, replacement; (h) A4285 — Polycarbonate bottle for use with breast pump, replacement; (i) A4286 — Locking ring for breast pump, replacement; (j) A4287 — Disposable collection and storage bag for breast milk, any size, any type; (k) A4288 — Valve for breast pump, replacement.