|
24.5.19 Breast Pumps
A breast pump is a benefit of Title XIX Home Health Services and requires prior authorization.
A manual breast pump may be considered for purchase only with the appropriate documentation supporting medical necessity.
The purchase of a breast pump is limited to one every three years. Use procedure codes J-E0602 or J-E0603 for the purchase of a manual or electronic breast pump.
An electric breast pump may be considered for purchase only with appropriate documentation supporting medical necessity and an explanation of why a manual breast pump was not effective. Supporting documentation may include an evaluation from a lactation consultant or RN, such as an experienced perinatal nurse.
Replacement of the breast pump will be considered when loss or irreparable damage has occurred, with a copy of the police or fire report when appropriate, and with the measures to be taken to prevent reoccurrence. Replacement will not be authorized in situations where the equipment has been abused or neglected by the client, the client's family, or the caregiver.
Procedure code J/L-E0604 for a hospital grade breast pump is not a benefit of Home Health Services.
Note: Breast pumps are also available through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).
|
