Covered and Noncovered Services : Home Health Equipment

Breast Pumps

According to the criteria listed below, breast pumps are covered. All of the following criteria must be met:

• The member recently delivered a baby and a physician has ordered or recommended mother's breastmilk for the infant.
• The member is capable of being trained to use the breast pump as indicated by the physician or provider.
• Current or expected physical separation of mother and infant (for example, illness, hospitalization, work) would make breastfeeding difficult or there is difficulty with "latch on" due to physical, emotional, or developmental problems of the mother or infant.

The provider who supplies the breast pump equipment is required to obtain and maintain on file the physician's order documenting the clinical requirements of the individual's need for a breast pump.

The maximum allowable fees include starter/accessory kits for all breast pumps. This includes single or double pumping kits. These kits are dispensed at the time the member is given the initial breast pump and cannot be reused by another individual.

For Purchase

Manual breast pumps of any type, including pedal powered, are covered under HCPCS procedure code E0602.

All types of electric breast pumps, AC or DC, are covered under procedure code E0603, that meet the following specifications:

• The pump must utilize suction and rhythm equivalent to the hospital-grade breast pump. This means it must have an adjustable suction pressure between 100 mm Hg and 250 mm Hg and a mechanism to prevent suction beyond 250 mm Hg.
• The pump must have an adjustable pumping speed capable of reaching 60 cycles per minute.

Breast pumps that do not meet these specifications are not covered.

PA is required for certain breast pump purchases.

For Rental

Heavy duty, hospital-grade electric breast pumps are covered under procedure code E0604.

For the rental of a breast pump, a higher per day reimbursement rate is allowed during the initial 30-day rental period for the costs associated with providing a new starter/accessory kit.

To obtain reimbursement for the new starter/accessory kit, providers are reminded to use modifier KH with procedure code E0604 for the initial 30-day rental period. Providers using the KH modifier will receive a total reimbursement rate of $3.06 per day during the initial 30-day rental period to cover costs for the initial starter/accessory kit as well as the breast pump rental.

Modifier KH may only be used with procedure code E0604 for the initial 30-day rental period. Claims with the KH modifier beyond the initial 30-day rental period for procedure code E0604 are denied.

PA is required if rental of a breast pump (E0604) exceeds 60 days.

Breast Pump Order Form

Providers are recommended to use the Breast Pump Order form; however, the use of this form is voluntary and providers may develop their own form as long as it includes all the information on the form.

The Breast Pump Order form is to be completed by the physician, given to the provider of the breast pump, and kept in the member's medical file as required under Wis. Admin. Code § DHS 106.02(9).