9092 Breast Pumps, Electric

Coverage of any medical intervention discussed in a Prevea360 Health Plan medical
policy is subject to the limitations and exclusions outlined in the member's benefit
certificate.
Breast Pumps, Electric
Covered Service:
MP9092
Yes–when meets criteria below
Prior Authorization
Required:
Yes–as shown below
Additional
Information:
Coverage for hospital-grade, heavy-duty electric breast pumps
(HCPCS code E0604) is discontinued when the infant is
discharged from the hospital or is feeding normally.
Prevea360 Health Plan Medical Policy:
1.0 Prevea360 Health Plan covers the purchase of one manual breast pumps (HCPCS
code E0602) or one personal-use electric breast pump (HCPCS code E0603) per
birth. This benefit does not require prior authorization through the Quality and Care
Management Division. The breast pump may be requested up to four weeks prior to
the member’s estimated delivery date if the member’s certificate or benefit plan allows.
1.1 This benefit is limited to one pump per birth. In the case of a birth resulting in
multiple infants, only one breast pump is covered.
1.2 A breast pump purchase includes the necessary supplies for the pump to
operate. For a personal-use electric breast pump this includes: standard power
adaptor, tubing adaptors, tubing, locking rings, bottles specific to breast pump
operation, caps for bottles that are specific to the breast pump, valves, filters, and
breast shield and/or splash protector for use with the breast pump.
2.0 Rental of a hospital-grade, heavy-duty electrical breast pump (HCPCS code E0604)
requires prior authorization through the Quality and Care Management Division and is
considered medically appropriate when the infant:
2.1 Remains in the hospital after the mother has gone home following delivery, or
2.2 Cannot breast feed due to congenital anomalies such as cleft palate and lip, other
anomalies of the tongue, or other specific anomalies of the mouth and pharynx.
3.0 Breastfeeding equipment and supplies not listed above are considered not medically
necessary. This includes, but is not limited to:
3.1 Batteries, battery-powered adaptors, and battery packs
3.2 Electrical power adapters for travel
3.3 Bottles which are not specific to breast pump operation. This includes the
associated bottle nipples, caps and lids
Breast Pumps, Electric
Underwritten by Dean Health Plan, Inc.
1 of 3
Coverage of any medical intervention discussed in a Prevea360 Health Plan medical
policy is subject to the limitations and exclusions outlined in the member's benefit
certificate.
3.4 Travel bags, and other similar travel or carrying accessories
3.5 Breast pump cleaning supplies including soap, sprays, wipes, steam cleaning
bags and other similar products
3.6 Baby weight scales
3.7 Garments or other products that allow hands-free pump operation
3.8 Breast milk storage bags, ice-packs, labels, labeling lids, and other similar
products
3.9 Nursing bras, bra pads, breast shells, nipple shields, and other similar products
3.10 Creams, ointments, and other products that relieve breastfeeding related
symptoms or conditions of the breasts or nipples
Breast Pumps, Electric
Underwritten by Dean Health Plan, Inc.
2 of 3
Coverage of any medical intervention discussed in a Prevea360 Health Plan medical
policy is subject to the limitations and exclusions outlined in the member's benefit
certificate.
Committee/Source
Date(s)
Originated:
Health Services Department
June 2, 1988
Revised:
—
—
Utilization Management Committee/Health Services
Utilization Management Committee/Medical Affairs
Medical Director Committee/Medical Affairs
Medical Director Committee/Medical Affairs
Medical Director Committee/Medical Affairs
Medical Policy Committee/Quality and Care
Management Division
May 31, 1991
June 1, 1994
February 11, 1998
January 16, 2008
February 23, 2012
August 19, 2015
September 2, 2015
Health Services
MCD/Medical Affairs Department
UMC/CMO/Director UM
UM Committee (UMC)/Director UM/UMC Chair
UM Committee (UMC)/Director UM/UMC Chair
UM Committee (UMC)/Director UM/UMC Chair
Reformatted
UM Committee (UMC)/Director UM/UMC Chair
UM Committee (UMC)/Director UM/ UMC Chair
UM Committee (UMC)/Director UM/ UMC Chair
UM Committee (UMC)/Director UM/UMC Chair
Medical Director Committee/Medical Affairs
Medical Director Committee/Medical Affairs
Medical Director Committee/Medical Affairs
Medical Director Committee/Medical Affairs
Medical Director Committee/Medical Affairs
Medical Director Committee/Medical Affairs
Medical Director Committee/Medical Affairs
Medical Director Committee/Medical Affairs
Medical Policy Committee/Quality and Care
Management Division
Medical Policy Committee/Quality and Care
Management Division
February 12, 1999
April 11, 2001
March 13, 2002
March 12, 2003
March 10, 2004
March 9, 2005
December 2005
March 8, 2006
March 14, 2007
March 12, 2008
April 8, 2009
August 18, 2010
August 25, 2011
February 23, 2012
August 15, 2012
July 17, 2013
July 16, 2014
July 15, 2015
August 19, 2015
Reviewed:
August 17, 2016
July 20, 2016
August 17, 2016
Effective: 09/01/2016
Breast Pumps, Electric
Underwritten by Dean Health Plan, Inc.
3 of 3

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