Breast Pumps

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BREAST PUMPS HS-027

Easy Choice Health Plan, Inc.

Harmony Health Plan of Illinois, Inc.

Missouri Care, Inc.

‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.

WellCare Health Insurance of Illinois, Inc.

WellCare Health Plans of New Jersey, Inc.

WellCare Health Insurance of Arizona, Inc.

WellCare of Florida, Inc.

WellCare of Connecticut, Inc.

WellCare of Georgia, Inc.

WellCare of Kentucky, Inc.

WellCare of Louisiana, Inc.

WellCare of New York, Inc.

WellCare of South Carolina, Inc.

WellCare of Texas, Inc.

WellCare Prescription Insurance, Inc.

Windsor Health Plan

Windsor Rx Medicare Prescription Drug Plan

Breast Pumps

(for Georgia, Hawaii and New York only) Policy Number: HS-027 Original Effective Date: 6/19/2008

Revised Date(s): 7/17/2009; 7/28/2010;

8/2/2011; 7/5/2012; 7/11/2013; 7/10/2014;

6/5/2015; 7/9/2015

APPLICATION STATEMENT

The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

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BREAST PUMPS HS-027

DISCLAIMER

The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member’s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult www.wellcare.com/Providers/CCGs for list of current LOBs.

BACKGROUND

An infant has a suction frequency of 40–126 sucks per minute. Pump simulation of these frequency values provides the best milk production results, because prolactin levels increase when the frequency is physiologically relevant.

When prolactin levels are high, the breast creates more milk and maintains the milk supply. Prolactin levels also increase when both breasts are emptied simultaneously. If a single pump is used, the pump should be switched from one breast to the other every five minutes. This approach is more effective than fully emptying one breast and then emptying the other (Biagioli, 2003). In addition to sucking frequency rates, most breast pumps are designed to empty a breast of its milk by simulating the suction pressure of an infant’s suckling. An infant feeds with a suction pressure of 50–220 millimeters of mercury (mm Hg). Suction pressure affects the mother’s comfort, efficiency of milk

expression and overall production level of milk. Pumps with suction pressures higher than 220 mm Hg may cause nipple discomfort. Maximal pressures of less than 50 mm Hg may be inadequate to empty the breast. Auto-cycling pumps provide an automatic release of the suction pressure, thereby allowing adequate tissue perfusion between suction cycles.

POSITION STATEMENT Applicable To:

Medicaid – Georgia Medicaid – Hawaii Medicaid – New York

Rental of a reusable breast pump is considered medically necessary durable medical equipment (DME) in the following two instances only:

1. For the period of time that a newborn is detained in the hospital after the mother is discharged; OR, 2. For babies who have congenital anomalies that interfere with feeding, breast pump rental is considered

medically necessary for the first month after discharge from the hospital.

Note: Breast pump rental is not considered medically necessary once newborn is discharged from hospital except for the instance noted in #2.

Nonreusable manual or electric breast pumps that are available commercially are not considered by WellCare to fall within the standard definition of durable medical equipment in that they are normally of use in the absence of illness or injury.

Georgia Medicaid

Breast pumps are to be used when there is a critical situation involving a mother and infant separation, and/or a medical problem. Breast feeding mothers who present the need should be targeted to receive a pump. The breast pump should be returned after the medical problem is resolved.

WellCare reimburses for an electric breast pump in the following situations:

 NICU babies (pre-term infants, infants with low birth weight)

 Infants readmitted to hospital

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BREAST PUMPS HS-027

 Infants with severe feeding problems (i.e., cleft palate) situations of maternal illness, and other medically necessary situations may be considered

Coverage applies only to electric breast pumps and kits provided after the mother is discharged from the hospital.

NOTE: Electric breast pumps will only be replaced once per three years. If the pump is used for multiple pregnancies during this three year period, only the breast pump kit will be replaced. It is the responsibility of the patient to keep this device for the expected lifetime of the equipment.

These pumps are single user (personal) pumps that will be patient owned and may be used for multiple pregnancies. Multi-user pumps are not covered by Georgia Medicaid.

NOTE: Electric Breast Pumps (E0603, E0604) will be purchase only with NU modifier effective October 1, 2013. Breast pumps will only be covered once per 3 years, and if the item is used for multiple pregnancies during the reasonable useful lifetime, only the kits will be covered.

A double pumping breast pump kit is an apparatus for the expression of breast milk. The system must be able to be used by attachment to an electric breast pump or manually. It must be capable of single or double pumping in either mode. WellCare will reimburse for one breast pump kit per member who requires the rental of the electric breast pump and has not received a kit through the hospital or a participating WIC program. After the breast pump has been returned, the breast pump kit remains the property of the member for continued manual use.

Replacement double pumping breast kit is by definition, an apparatus for the expression of breast milk, but

considered to be an additional kit for the purpose of reimbursement through Georgia Medicaid if the mother has an additional pregnancy within three years and the baby meets policy coverage criteral (a-). The system must be capable of lateral or bilateral pumping. Members can receive one (1) replacement double pumping breast kit which includes 2 bottles, 2 breast shields, 2 tubes, and 2 vales, per member who requires the purchase of the electric breast pump and has not received a kit through the hospital or a participating WIC program.

Hawaii Medicaid

Breast pumps are considered a covered pregnancy-related service. A breast pump may be purchased OR rented for six months. Prior authorization is required.

Breast pumps are considered medically necessary for members meeting one of the following criteria:

 Breast conditions, like engorgement, infection, breast abscess and fibrocystic breasts; OR,

 Nipple conditions, like itchy, bleeding, sore nipples, and pain or fissures in nipples; OR,

 Supplementation for low milk supply, or any lactation risk factors; OR,

 Expressing milk after delivering a stillborn infant; OR,

 Need to go to work or school; OR,

 Any other reason which prevents breastfeeding; OR,

 Having normal pregnancy and/or healthy baby.

Members can request for breast pumps at any time during the 3rd trimester (29-40 weeks) of their pregnancy or postpartum.

In addition, breast pumps are considered medically necessary for infants with any one of the following:

 Having difficulty latching-on or difficulty feeding at the breast; OR,

 Having genetic, neurologic, or other medical conditions; OR,

 Was born premature, or late preterm.

Exclusions and Limitations

1. WellCare will cover the purchase of one (1) standard electric breast pump per pregnancy.

2. WellCare will not cover the replacement of breast pumps and supplies. If a breast pump is broken under the warranty, members are directed to contact the manufacturer or supplier.

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BREAST PUMPS HS-027

New York Medicaid

Rental of hospital grade breast pumps for use in the home requires prior approval; rental is limited to Durable Medical Equipment vendors. Coverage is limited to the following indications (New York Medicaid Manual):

 Prematurity (including multiple gestation)

 Neurologic disorders

 Genetic abnormalities (e.g. Down’s Syndrome)

 Anatomic and mechanical malformations (e.g. cleft lip and palate)

 Congenital malformations requiring surgery (e.g. respiratory, cardiac, gastrointestinal, central nervous system)

 Prolonged infant hospitalization

 Other conditions that prevent normal breastfeeding (e.g. respiratory compromise)

A Dispensing Validation System (DVS) authorization is available for up to 2 months. Prior approval is required for cases requiring more than 2 months rental (e.g. extreme prematurity, less than 28 weeks gestation).

Pumps should be prescribed in coordination with lactation services to determine the best type of pump:

 Manual pumps (single-user) are appropriate for daily milk expression or occasional use, depending on the mother's life schedule such as working part-time.

 Personal use (single-user) double electric pumps are intended for mothers who are returning to work or school, have an established milk supply, and are anticipating long-term use.

 Personal use (single-user) single electric pumps are not recommended since they are not effective in maintaining a long-term milk supply or when pumping during short time periods such as work breaks.

 Hospital grade, multi-user pumps (with a single-user, double pumping kit) are designed for short and long- term use based on the mother's and infant's health situation, and appropriate for women who need to establish their milk supply.

Members can receive three types of breast pumps based on whether they meet the minimum breast pump specifications. For details regarding minimum pump specifications and reimbursement for breast pumps, go to:

www.emedny.org/ProviderManuals/DME/communications.aspx

CODING

Georgia Medicaid

CPT® Codes - No applicable codes.

Covered HCPCS Level II Codes

A4281 - A4286 Breast pump supplies [for rented reusable breast pump pumps only]

E0602 Breast pump, manual, any type [rented reusable only]

E0603 Breast pump, electric (AC and/or DC), any type [rented reusable only]

E0604 Breast pump, hospital grade, electric (AC and/or DC), any type (rented reusable only) NOTE: Electric Breast Pumps (E0603, E0604) will be purchase only with NU modifier effective October 1, 2013. Breast pumps will only be covered once per 3 years, and if the item is used for multiple pregnancies during the reasonable useful lifetime, only the kits will be covered.

ICD-9 Procedure Codes - No applicable codes.

DRAFT ICD-10-PCS Codes - No applicable codes.

Covered ICD-9 Diagnosis codes*

749.00 - 749.25 Cleft palate and cleft lip 750.0 Tongue tie

750.10 - 750.19 Tongue tie and other anomalies of tongue

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BREAST PUMPS HS-027

750.21 - 750.29 Other specified anomalies of mouth and pharynx 764.01 - 764.09 Light for dates without mention of fetal malnutrition 765.01 - 765.15 Extreme immaturity and Other preterm infants

765.21 - 765.28 Weeks of Gestation; less than 24 completed weeks of gestation through 35-36 completed weeks of gestation

Covered Draft ICD-10-CM Diagnosis Codes Q35.1 - Q35.9 Cleft palate

Q36.0 - Q36.9 Cleft lip

Q37.0 - Q37.9 Cleft palate with cleft lip

Q38.0 - Q38.8 Other congenital malformations of tongue, mouth and pharynx P05.01 - P05.08 Newborn light for gestational age

P05.11 - P05.18 Newborn small for gestational age P07.01 - P07.03 Extremely low birth weight newborn P07.14 - P07.18 Other low birth weight newborn P07.21 - P07.26 Extreme immaturity of newborn P07.31 - P07.39 Preterm [premature] newborn [other]

* This list of codes may not be all-inclusive of congenital anomalies that interfere with feeding of the newborn. Documentation is required to establish medical necessity.

Hawaii Medicaid

CPT® Codes - No applicable codes Covered HCPCS Level II Codes

A4281 - A4286 Breast pump supplies [for rented reusable breast pump pumps only]

E0604 Breast pump, hospital grade, electric (AC and/or DC), any type (rented reusable only ICD-9 Procedure Codes - No applicable codes

DRAFT ICD-10-PCS Codes - No applicable codes Covered ICD-9 Diagnosis codes*

610.0-612.1 Disorders of breast 749.00 - 749.25 Cleft palate and cleft lip 750.0 Tongue tie

750.10 - 750.19 Tongue tie and other anomalies of tongue 750.21 - 750.29 Other specified anomalies of mouth and pharynx 764.01 - 764.09 Light for dates without mention of fetal malnutrition 765.01 - 765.15 Extreme immaturity and Other preterm infants

765.21 - 765.28 Weeks of Gestation; less than 24 completed weeks of gestation through 35-36 completed weeks of gestation

779.31 Feeding problem in newborn Covered Draft ICD-10-CM Diagnosis Codes N60.01-N65.1 Disorders of breast

Q35.1 - Q35.9 Cleft palate Q36.0 - Q36.9 Cleft lip

Q38.0 - Q38.8 Other congenital malformations of tongue, mouth and pharynx P05.01 - P05.08 Newborn light for gestational age

P05.11 - P05.18 Newborn small for gestational age

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BREAST PUMPS HS-027

P07.01 - P07.03 Extremely low birth weight newborn P07.14 - P07.18 Other low birth weight newborn P07.21 - P07.26 Extreme immaturity of newborn P07.31 - P07.39 Preterm [premature] newborn [other]

P92.1-P92.9 Feeding problems of newborn

* This list of codes may not be all-inclusive of genetic, neurologic, or other medical conditions of infants. Documentation is required to establish medical necessity. Please refer to the Policy statement above for further diagnostic coverage.

New York Medicaid

CPT® Codes - No applicable codes.

Covered HCPCS Level II Codes for Rental of Breast Pumps for Home Use A4281 - A4286 Breast pump supplies [for rented reusable breast pump, pumps only]

E0604** Breast pump, hospital grade, electric (AC and/or DC), any type (rented reusable only) **Limited coverage, refer to the New York Medicaid Manual Text coverage statement above.

ICD-9 Procedure Codes - No applicable codes.

DRAFT ICD-10-PCS Codes - No applicable codes.

Covered ICD-9 Diagnosis Codes*

749.00 - 749.25 Cleft palate and cleft lip 750.0 Tongue tie

750.10 - 750.19 Tongue tie and other anomalies of tongue 750.21 - 750.29 Other specified anomalies of mouth and pharynx 758.0 Down’s Syndrome

765.01 – 765.03 Extreme immaturity with a birthweight of less than 1000 grams 765.14 – 765.18 Other preterm infants with a birthweight of 1000 to 2499 grams 770.7 Chronic respiratory disease arising in the perinatal period Covered Draft ICD-10-CM Diagnosis Codes

Q35.1 - Q35.9 Cleft palate Q36.0 - Q36.9 Cleft lip

Q38.0 - Q38.8 Other congenital malformations of tongue, mouth and pharynx Q90.0 - Q90.9 Down Syndrome (Trisomy 21)

P05.01 - P05.08 Newborn light for gestational age P05.11 - P05.18 Newborn small for gestational age P07.01 - P07.03 Extremely low birth weight newborn P07.14 - P07.18 Other low birth weight newborn P07.21 - P07.26 Extreme immaturity of newborn P07.31 - P07.39 Preterm [premature] newborn [other]

P27.0 - P27.9 Chronic respiratory disease originating in the perinatal period

* This list of codes may not be all-inclusive of congenital anomalies that interfere with feeding of the newborn. Documentation is required to establish medical necessity. Please refer to the Policy statement above for further diagnostic coverage.

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BREAST PUMPS HS-027

REFERENCES

1. Georgia Department of Community Health Division of Medicaid. (2014, April). Durable medical equipment services (Section 806.12).

Retrieved from https://www.mmis.georgia.gov/portal/PubAccess.Home/tabId/36/Default.aspx

2. New York State Medicaid Program. (2013, March). Minimum breast pump specifications established for Medicaid reimbursement. Retrieved from https://www.emedny.org

3. New York State Medicaid Program. (2013, March). New York stated Medicaid coverage of breast pumps. Retrieved from http://www.health.ny.gov/community/pregnancy/breastfeeding/medicaid_coverage/ breast_pump_coverage.htm

4. New York State Medicaid Program. (2013, April). Durable medical equipment, orthotics, prosthetics and supplies: procedure codes and coverage guidelines. Retrieved from https://www.emedny.org/ProviderManuals/ DME/PDFS/DME_Policy_Section.pdf

MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS

Date Action

7/9/2015  Approved by MPC. Inclusion of coverage for Hawaii.

6/4/2015, 7/10/2014, 7/11/2013  Approved by MPC. No changes.

7/5/2012  Approved by MPC. Added criteria for Georgia Medicaid.

12/1/2011  New template design approved by MPC.

8/2/2011  Approved by MPC. No changes.