Description:
A breast pump is a mechanical device used to extract milk from a lactating mother. There are three basic types:

1. Manual breast pump (E0602): a nonelectric pump that works by vacuum suction generated through biomechanical effort.
2. Standard electric breast pump (E0603): an electric pump that works by creating pulsating suction, usually by pneumatic action against a diaphragm.
3. Hospital-grade heavy-duty electric breast pump (E0604): a piston-operated electric pump with pulsatile vacuum suction and release cycles. This item is available for rental only.

Background:
Breastfed infants have a lower risk of diarrhea and otitis media than bottle-fed infants during the first year of life. For premature infants, breast milk may assist in preventing infections, speeding recovery from respiratory distress syndrome, increasing weight gain, protecting against retinopathy, and facilitating cognitive and visual development. 

Breast pump rental may be medically appropriate for infants while they are detained in the hospital. Breast pumps used in the hospital are specifically designed for reuse (able to be sterilized) and are not sold commercially. The 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 are not always home to breastfeed the baby. Standard electric breast pumps or manual breast pumps may be appropriate to initiate breastfeeding in the postpartum period, within the first eight weeks following delivery. Manual breast pumps are sufficient for continuation of breastfeeding following the postpartum period. Current recommendations from the American Academy of Pediatrics are to continue breastfeeding in infants through one year.

Policy Statement:
A dual manual (E0602) or a standard, dual electric breast pump (E0603) is MEDICALLY APPROPRIATE for purchase for all women who choose to breastfeed. (See notes below; this benefit is specific to nongrandfathered plan members only.)

Rental of a heavy-duty, hospital-grade electric breast pump (E0604) and purchase of necessary supplies is MEDICALLY APPROPRIATE during the time a mother and infant are separated because the infant remains hospitalized upon the mother's discharge.

Continued rental of a hospital-grade electric pump is considered NOT MEDICALLY NECESSARY once the baby has been discharged. The purchase of a standard electric breast pump (E0603) will be covered.

Supplies necessary for use of a breast pump, such as tubing (A4281) and adapter (A4282), are MEDICALLY APPROPRIATE and covered as necessary.

Replacement supplies primarily for comfort and convenience (A4283, A4284, A4285 and A4286) and milk storage products are not covered, as they are NOT MEDICALLY NECESSARY. (terminated 12/31/2022)

Effective Jan. 1, 2023 A4283, A4284, A4285, A4286 and K1005 will be considered MEDICALLY NECESSARY.

NOTE: Breast pumps must be obtained from contracted, network providers for in-network benefits to apply. All other providers, including retail or online vendors, are considered out of network.

NOTE: For members who qualify for no cost sharing in relation to breast pump purchases, there are two allowable pumps available: the Ameda Purely Yours electric pump and the Ameda One Hand manual pump. The Ameda Purely Yours pump was discontinued by the manufacturer in late 2017. It has been replaced by the Ameda Finesse pump, and this replacement model will be considered allowable for the no cost sharing breast pump purchases. The Ameda Finesse model will be discontinued in 2019 and replaced with the Ameda Mya model. The Mya model will now be considered allowable for the no cost sharing breast pump purchases. Effective February 2020, the Medela In-style pump will also be considered allowable for the no cost sharing breast pump purchases.

NOTE: The Medela In-style pump will be discontinued in 2021 and replaced with the Medela Pump In Style Advanced model. The Pump In Style Advanced model will now be considered for the no cost sharing breast pump purchases.

NOTE: The Medela In-Style pump has been updated to Medela Pump in Style with Maxflow for 2022.

NOTE: The Ameda Mya pump will be replaced by the Ameda Mya Joy pump. (November 2021)

References:

1. Pickering LK, Baker CJ, Long SS, McMillan JA, Eds. American Academy of Pediatrics (AAP).  Human milk.  In:  2006 Red Book; Report of the Committee on Infectious Disease. 26th Ed/  Elk Grove Village, IL:  AAP:  123-130.
2. Beaudry M, Dufour R, Marcoux S.  Relation between infant feeding and infections during the first six months of life.  J Pediatr.  1995; 126(2):  191-197.
3. Bier JB, Ferguson A, Anderson L, et al.  Breast-feeding of very low birth weight infants.  J Pediatr.  1993; 123(5):  773-778.
4. Dewey KG, Heninig MJ, Nommsen-Rivers LA.  Difference in morbidity between breast-fed adn formula-fed infants.  J pediatr.  1995; 126(5 Pt 1):  696-702.
5. Anderson JS, Johnstone Bm, Remley DT.  Breast-feeding and cognitive development; a meta-analysis.  Am J Clin Nutr.  1999; 70(4):  525-535.
6. Kramer MS, Kakuma R.  Optimal duration of exclusive breast-feeding.  Cochrane Database Syst Rev.  2002; (1):  CD003517
7. Henderson G, Anthony MY, McGuire W.  Formulamilk versus maternal breast milk for feeding preterm or low birth weight infants.  Cochrane Database Syst Rev.  2007; (4):  CD002971.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward     

01/01/2024 NEW POLICY