Information posted July 28, 2017
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after September 1, 2017, breastfeeding support services will change for Texas Medicaid.
This article addresses breast pump equipment provided by durable medical equipment (DME) suppliers and medical supply companies in the home setting.
A breast pump may be reimbursed under an eligible infant’s Texas Medicaid client number.
Overview of Benefit Changes
Major changes to this medical benefit policy include the following:
- Identifying the infant as the only client for which services may be reimbursed
- The addition of breast pump equipment specifications
- New medical necessity criteria for mothers and infants
- Updated frequency limitations for breast pumps and parts
- Changes to prior authorization requirements
- Updated documentation requirements
Breast Pump Specifications
The following breast pump procedure codes are a benefit of Texas Medicaid:
|Procedure Code||Additional Information|
A4281, A4282, A4283, A4284, A4285, A4286
Breast pump parts for use with a pump that has been purchased.
All parts must be submitted with modifier U8.
Purchase of a personal-use, manual breast pump
Purchase of a personal-use, electric breast pump
Rental of a multiple-user, hospital-grade electric breast pump
All breast pumps must meet the following specifications:
- Comply, be registered, and be cleared with the Federal Drug Administration (FDA)
- Allow for pumping sessions to be efficiently completed within 30 minutes
- Be adaptable for several sizes of breast shields (flanges), including larger sizes, so as to accommodate different sizes of breasts and nipples
- Have an adjustable and wide-range of suction pressure at the breast shield during use, typically from 30 millimeters of mercury up to 250 millimeters of mercury (mm Hg)
- Have a mechanism or written guidelines to prevent or instruct the user from achieving a vacuum level over 250 mm Hg
- Be portable
Personal-Use Breast Pump (Manual and Electric) Specifications
Each type of personal-use breast pump must meet the following specifications:
- Manual breast pump
- Include an independent milk collection bottle. The pump cylinder must not be the milk-collecting container.
- Electric breast pump
- Be adaptable for simultaneous pumping of both breasts (double-collection)
- Have an adjustable suction pressure range necessary for preventing nipple trauma
- Automatically cycle with an adjustable variable cycling rate, typically 30 to 60 or more cycles per minute
- Include a battery option and adapter to be used as an alternate power source when electricity is not immediately available
Note: Personal-use, single-collection electric pumps cannot simultaneously pump both breasts. Single-collection pumps are not recommended, as they are neither effective in maintaining a long-term milk supply nor efficient when pumping during short periods, such as work breaks. Double-collection breast pumps are the standard personal-use electric pump recommended by Texas Medicaid for breastfeeding infants and mothers.
Hospital-Grade Electric Breast Pump Specifications
A hospital-grade electric breast pump must meet the following specifications:
- Be adaptable for simultaneous pumping of both breasts with an adjustable suction for preventing nipple trauma
- Automatically cycle with adjustable or variable cycling that closely mimics the suckling action of an infant, typically a rate of 30 to 60 or more cycles per minute
- Electrical (AC and/or DC) with a piston-driven motor
- Include an adapter to be used as an alternate power source when electricity is not immediately available
- Must not allow milk to contact the housing unit or internal pump-motor at any time when the multiple-user pump is used per manufacturer's instructions
Breast Pump Kit Specifications
A breast pump kit is included in the purchase or rental of a breast pump, and is not separately reimbursed. Kits should include the following:
- Breast shields (flanges) that are adjustable and flexible, or flanges that are available in several different sizes if rigid, including larger sizes
- All accessories necessary for pumping two breasts simultaneously for electric pumps, or at least one breast manually for manual handle-squeeze pumps
- All parts necessary to easily convert an electric pump to a manual pump (e.g., piston cylinder assembly and pump connector; manual pump adapter; conversion kit)
- At least two extra sets of membrane and valve replacements
- At least one extra diaphragm replacement for closed-system pumps
- At least two collection bottles with spill-proof standard size caps, that are bisphenol-A (BPA) and DEHP-free
- Accessories and supplies must be compatible with the pump provided. Materials must be of durable quality for withstanding repeated boiling, washing, and pumping use.
Medical Necessity Criteria
Breastfeeding is encouraged as a means to prevent various illnesses and conditions and to promote the health and wellness of mothers and infants. In some circumstances, breast pumps may be medically necessary for breastfeeding.
Personal-Use Manual Breast Pump Criteria
Manual breast pumps (procedure code E0602) are appropriate for short-term or occasional uses related to, but not limited to, any of the following:
- Infrequent separation from infants; such as mothers who work or go to school part-time for less than 10 hours per week, and who do not meet criteria for electric or hospital-grade pumps.
- Resolving brief uncomplicated periods of plugged duct
- Short-term concerns of mild engorgement
- Flat, retracted, or inverted nipples, and the mother does not meet the criteria for electric or hospital-grade pumps
- Cracked or fissured nipples, and the mother does not meet the criteria for electric or hospital-grade pumps
Note: Manual breast pumps are not recommended for pumping on a regular basis, or for attempting to establish a milk supply.
Personal-Use Electric Breast Pump Criteria
Personal use double-collection electric breast pumps (procedure code E0603) are for mothers and infants who are breastfeeding with limited, minor, or no complications. Personal-use double-collection electric breast pumps are recommended for pumping and maintaining a milk supply related to, but not limited to, any of the following:
- Regular separation from infants; such as mothers returning to work or school for 10 or more hours per week
Infants detained in the hospital, who do not meet the criteria for a multiple-user electric breast pump
- Significant breast engorgement
- Breast abscess
- If the mother is to receive short-term treatment with medication or therapies that may be transmitted through breast milk, but she wishes to maintain her milk supply by pumping and discarding her milk in the interim
Hospital-Grade Electric Breast Pump Criteria
Rental of a multiple-user, hospital-grade electric breast pump (procedure code E0604) is recommended for moderate to significant breastfeeding complications. Hospital-grade electric breast pumps are recommended for pumping related to, but not limited to, any of the following:
- Infants who cannot suck well, or have an uncoordinated swallow/suck reflex, due to respiratory disease or congenital disorder
- Infants diagnosed with failure to thrive, cardiac problems, or other special needs
- Infants who are chronically ill
- Infants of low birth-weight with increased nutritional needs
- Infants with severe feeding or digestive problems, as described by the provider in documentation
- Prematurity (less than 37 weeks gestation)
- Multiple births (e.g., twins, triplets, etc.)
- Long-term separation of mother and infant due to hospitalization
- Mothers experiencing conditions affecting their milk production, or low-milk supply, as described in documentation by the prescribing provider familiar with the client
- Mothers needing to induce lactation for establishing their milk supply, but are unable to do so without a hospital-grade breast pump
Note: A closed-system pump requires a personal-use milk collection pump kit, included in the rental, but to be kept by the individual and not for return with the pump.
Breast pumps and related parts will be limited as follows:
Once within 12 months from the date of birth
Initial 60-day rental, followed by up to three 90-day rentals within 12 months from the date of birth
A4281, A4282, A4283, A4284, A4285,
Each part - up to 2 times within 12 months from
the breast pump date of purchase
*Only one of these procedure codes may be reimbursed when submitted for the same date of service by any provider
Procedure codes E0602 and E0603 will be denied when submitted within the same calendar month as procedure code E0604.
Procedure code E0602 will be denied when submitted within one year from procedure code E0603, any provider.
All breast pump parts must be billed with modifier U8:
Modifier U8 identifies the replacement of a part for a breast pump
Replacement part procedure codes will be denied when submitted for the same date of service as a breast pump.
If the breast pump was not purchased by Texas Medicaid and requires replacement parts, the following documentation of a client-owned device must be submitted:
- Purchase date
- Serial number
- Purchasing entity of the device
- Copy of the receipt, if available
Note: Parts for a hospital-grade electric breast pump (procedure code E0604), and routine servicing and all necessary repairs to ensure the unit remains functional for the client's needs, are included in the rental of the pump and is the responsibility of the DME supplier.
Prior Authorization Requirements
Prior authorization requests must include the following:
- A completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form prescribing the durable medical equipment, signed and dated by the prescribing provider familiar with the client
- The prescribing provider must provide correct and complete information on the form, including accurate medical necessity of the equipment requested.
To complete the prior authorization process, the DME provider must submit the completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form to the THMP Home Health Unit.
Personal-Use Breast Pump (Manual and Electric) Prior Authorization Requirements
Prior authorization will not be required for the initial purchase of a manual or electric personal-use breast pump.
Prior authorization will be required for the replacement of a manual or electric personal-use breast pump due to damage or loss, within 12 months from the purchase date.
Requests for the replacement of a Texas Medicaid purchased personal-use breast pump (procedure code E0602 or E0603) must include the following documentation:
- A statement from the provider describing the loss or damage and what measures will be taken to prevent reoccurrence
- A copy of the police or fire report, when appropriate. The report must also be maintained in the client’s medical record.
Note: HHSC or its designee reserves the right to request additional documentation about the need for replacement when there is evidence of abuse or neglect to equipment by the client, client's family, or caregiver. Requests for replacement when there is documented proof of abuse or neglect will not be approved.
Hospital-Grade Electric Breast Pump Prior Authorization Requirements
Prior authorization will not be required for the initial 60-day rental of a multiple-user hospital grade electric breast pump (procedure code E0604).
Prior authorization will be required after the initial 60-day rental period. Requests may be considered for 90-day increments only.
A maximum of 3 prior-authorized 90-day increments will be allowed within the 12 months following birth.
If an infant with medical necessity requires the extended rental of a hospital-grade electric breast pump, beyond these limitations, the claim may be considered for reimbursement upon appeal with documentation. The prescribing provider familiar with the client must identify pumping as the mother's primary method for expressing her breastmilk, and must include a statement that clearly describes the infant's medical necessity. Medically necessary conditions may include the following:
- Short-bowel syndrome
- Severe malabsorption syndromes
- Severe feeding intolerances or immunological deficiencies
Clients who no longer qualify for the continued rental of a hospital-grade breast pump may still qualify for the purchase of a breast pump as outlined in this article.
A hospital-grade electric breast pump will be considered purchased and owned by the client when the monthly payments for rental, through the same provider, equals the purchase cost for the equipment. The following will be required:
- The DME provider must notify the client when the rental equipment is considered purchased due to an extended rental. Proof of ownership must be provided to the client by the DME provider.
- Proof of client ownership of the device is required for reimbursement of replacement parts
- A statement from the DME provider indicating the make and model of the client-owned device, along with proof of client ownership, must be submitted with claim appeals for reimbursement of parts.
A hospital-grade breast pump that has been purchased due to extended rental is anticipated to last the minimum timeframe indicated by the manufacturer's warranty.
Replacement Parts Prior Authorization Requirements
Prior authorization will not be required for up to 2 replacements of each part within 12 months from the breast pump’s date of purchase.
Prior authorization will be required when the maximum limitation of 2 will be exceeded.
Requests must be submitted with appropriate documentation to support the need for additional replacement parts. The following documentation must be included under "If applicable" in section B of the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form:
- The provider must attest that the mother continues to use the equipment for breastfeeding.
- The provider must indicate that the requested part is required for improved pumping efficiency (e.g., larger flanges), or is damaged or lost and affecting the function of the pump.
Direct care providers must maintain the following documentation in the client’s medical record:
- Client’s specific medical necessity regarding the specific type of breast pump equipment ordered
- Anticipated duration of need regarding the circumstances or conditions related to the type of equipment ordered
- Infant's age (or gestational age, if premature)
- Documentation of the mother's intent to breastfeed
Services That Are Not a Benefit
The following breastfeeding support services are not benefits of Texas Medicaid:
- Personal-use electric breast pumps that are only capable of single-collection pumping, one breast at a time
- Breastfeeding support services in the preconception or prenatal period
- Breastfeeding support services for infants who are not breastfeeding and the mother has no intent to breastfeed
Benefit information for breastfeeding support services will be published in the September release of the Texas Medicaid Provider Procedures Manual, Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook.
For more information, call the TMHP Contact Center at 1-800-925-9126.