Definition A hospital grade electric breast pump is heavy duty, piston-operated, and is capable of being used frequently on a daily basis.
Standards of Coverage
A hospital grade electric breast pump may only be covered for a beneficiary with a Neonatal Intensive Care Unit (NICU) infant, up to three months of age, when one of the following applies:
* The infant has a severe feeding problem secondary to cleft lip and/or palate.
* The infant has a severe feeding problem due to oral motor dysfunction, secondary to prematurity.
* The infant is hospitalized resulting in a physical separation of the mother and infant.
* The infant or mother is hospitalized, resulting in a physical separation of the mother and infant; and all of the following applies:
* The pump has an adjustable suction pressure at the breast shield during use between 30 mm Hg and 250 mm Hg (suction just at the low or high end is not acceptable);
* The pump has a mechanism to prevent suction beyond 250 mm Hg to prevent nipple trauma;
* The pump has an adjustable/varying pumping speed no less than 30 cycles per minute and capable of reaching up to a maximum of 60 cycles per minute;
* The pump must be able to operate on a 110-volt household current and be UL listed;
* The pump must not weigh over 12 pounds; and
* The pump is registered and cleared with the FDA.
For continued coverage beyond the initial three months, additional documentation must be provided.
Documentation Documentation must be less than 30 days old and include:
* Diagnosis/medical condition of the infant relating to the need for a breast pump.
* Infant's age (gestational age, if premature).
* Mother's discharge date.
* Anticipated duration of need.
* An order signed by the treating physician or non-physician practitioner.
* The International Classification of Diseases (ICD) diagnosis code(s) related to birth or pregnancy.
* Documentation of mother’s intent to breastfeed.
Documentation must be kept in the beneficiary’s file and made available upon request.
PA Requirements PA is not required when the Standards of Coverage are met.
PA is required for coverage beyond three months
Payment Rules A breast pump is considered a rental only item and is inclusive of the following:
* All related accessories necessary to use the equipment. (To obtain additional reimbursement for the initial breast pump kit, report the "KH" modifier with HCPCS code E0604 for the first month of rental only.)
* Education on the proper use and care of the equipment.
* Routine servicing and all necessary repairs or replacements to make the unit functional.
The rental pump may be billed using the infant's Medicaid ID number if the need for the hospital grade pump meets the standards of coverage and the mother loses Medicaid eligibility.
Rental of the hospital-grade electric breast pump will not be made if a personal use double electric breast pump or a manual breast pump was purchased for the beneficiary within the Standards of Coverage frequency limitations.
PERSONAL USE DOUBLE ELECTRIC BREAST PUMP
Definition A personal use double electric breast pump is defined as a double electric (AC and/or DC) pump, intended for a single user, capable of being used frequently on a daily basis.
Standards of Coverage
A personal use double electric breast pump may be covered once per five years for a beneficiary when all of the following criteria are met:
* The mother expresses the desire to breastfeed;
* The pump has been registered and cleared by the FDA;
* The pump has a minimum of a one-year manufacturer’s warranty;
* The pump has an adjustable suction pressure at the breast shield during use between 30 mm Hg and 250 mm Hg (suction just at the low or high end is not acceptable);
* The pump has a mechanism to prevent suction beyond 250 mm Hg to prevent nipple trauma;
* The pump has an adjustable/varying pumping speed no less than 30 cycles per minute and capable of reaching up to a maximum of 60 cycles per minute;
* The pump must be able to operate on a 110-volt household current and be UL listed;
* The pump must not weigh over 12 pounds; and
* The pump collection bottle must be bisphenol-A (BPA) and DHEP-free.
Documentation Must be less than 30 days old and include all of the following:
* An order signed by the treating physician or non-physician practitioner.
* The International Classification of Diseases (ICD) diagnosis code(s) related to birth or pregnancy.
* Infant’s age (gestational age, if premature).
* Mother’s hospital discharge date or infant’s hospital discharge date.
* Documentation of mother’s intent to breastfeed.
Documentation must be kept in the beneficiary’s file and made available upon request. PA Requirements PA is not required when the Standards of Coverage are met. PA is required for circumstances beyond the Standards of Coverage and Payment Rules.
Payment Rules All personal use double electric breast pumps are purchase only. Payment includes:
* Education for the proper use, care of the equipment, and storage of breast milk.
* Supplies necessary for operation of the pump (pump, adapter/charger, breast shields, bottles, lids, tubing, locking ring, connectors, valves, filters and membranes.
The pump may be billed using the infant’s Medicaid ID number if the need for the pump meets the Standards of Coverage and the mother loses Medicaid eligibility. Medicaid will not purchase a personal use double electric breast pump during the rental period of a hospital-grade electric breast pump or if a manual breast pump was purchased within the Standards of Coverage frequency limitations.
Replacement parts are covered after the manufacturer’s warranty has expired for included parts. Refer to the Medical Supplier database and the Medicaid Code and Rate Reference tool for covered replacement parts, code descriptions, coverage limitations and reimbursement.
MANUAL BREAST PUMP
Definition A manual breast pump typically consists of a single breast shield, a collection device, and a hand-controlled lever to create suction and express milk. Manual breast pumps are intended for a single user.
Standards of Coverage
A manual breast pump may be covered once per birth. For a beneficiary who has had a multiple birth delivery, only one pump is covered. Coverage of a manual breast pump may be provided when all of the following criteria have been met:
* The mother expresses the desire to breastfeed.
* The pump has been registered with the FDA.
* The pump has a minimum of a one year manufacturer’s warranty.
* The pump has a mechanism to prevent suction beyond 250 mm Hg to prevent nipple trauma.
* The pump collection bottle must be bisphenol-A (BPA) and DHEP-free.
Definition Diabetic shoes, inserts and related modifications include, but are not limited to, depth inlay shoes, multi-density inserts, roller or rocker bottoms, wedges, metatarsal bar, and offset heel.
Standards of Coverage
Diabetic shoes, inserts, and/or modifications may be covered for individuals who have, due to complications with diabetes mellitus, one of the following conditions:
* History of previous foot ulcerations or pre-ulcerative calluses.
* Established peripheral neuropathy or sensory impairment.
* Peripheral Vascular Disease with an ankle brachial index at rest of 0.5 or less following exercise.
* Loss of a toe or portion of the foot due to amputation arising from diabetes.
A custom-molded diabetic shoe is covered only if the depth shoe cannot accommodate a foot anomaly.
Inserts are covered if the beneficiary requires a depth shoe or custom-molded diabetic shoe. For a depth shoe, three inserts would be separately reimbursable in addition to the noncustomized one included with the shoe. For a custom-molded shoe, two inserts would be separately reimbursable. Modifications to a custom-molded or depth shoe may be covered rather than an additional insert.
Documentation Documentation must be less than 30 days old and include all of the following:
* Diagnosis/medical condition related to the service requested.
* Medical reasons for specific shoe type and/or modification.
PA Requirements PA is not required for the following inserts if the Standards of Coverage are met:
* Multiple density insert, direct formed, molded to foot with external heat source.
* Multiple density insert, direct formed, compression molded to patient's foot without external heat source.
* Multiple density insert, custom fabricated and custom-molded from model of patient's foot.
* Depth inlay shoes.
* Modifications if an additional insert is not provided.
PA is required for:
* Medical need beyond the Standards of Coverage.
* Replacement within one year.
* Quantity beyond established limits.
* Custom-fabricated shoes and other inserts not included above. Payment Rules All items are considered purchase only.
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