4.1 Heavy-Duty
Hospital Grade Breast Pumps And Supplies
4.1.1 For
services rendered between August 8, 2005, and December 18, 2014,
a heavy-duty hospital grade breast pump (E0604) is covered (including
services and supplies related to the use of the pump) for mothers
of premature infants only.
4.1.1.1 A
premature infant is defined as a newborn with International Classification
of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes
765.0 (extreme immaturity), 765.1 (other preterm infants), or 765.21
through 765.28 (up to 36 weeks gestation) for services provided
before the mandated date, as directed by Health and Human Services
(HHS), for International Classification of Diseases, 10th Revision
(ICD-10) implementation or ICD-10-CM codes P07.00 - P07.03 (extremely
low birth weight (unspecified weight-999 grams)), P07.10 - P07.18
(other low birth weight (unspecified weight, 1000-2499 grams)),
P07.20 - P07.26 (extreme immaturity (unspecified weeks-27 completed weeks)),
P07.30 - P07.39 (other preterm (unspecified, 28-36 completed weeks))
for services provided on or after the mandated date, as directed
by HHS, for ICD-10 implementation.
4.1.1.2 A heavy-duty
hospital grade breast pump is covered while the premature infant
remains hospitalized during the immediate postpartum period.
4.1.1.3 After the
premature infant (as defined in
paragraph 4.1.1.1) is discharged, continued
use of a hospital-grade breast pump may be covered when a physician
documents the medical reason for continued use.
4.1.1.4 Regular
Durable Medical Equipment (DME) and supply cost-sharing rules apply.
4.1.2 For services
rendered on or after December 19, 2014, a heavy-duty hospital grade
breast pump (E0604) and associated supplies are covered when required
to support initiation of lactation for mothers and infants who are
separated due to illness or who are unable to feed directly from
the breast due to maternal or infant medical complications, congenital
anomalies, induced lactation, relactation, adoption, or other medical
conditions for mother or infant which preclude effective feeding
at the breast.
4.1.2.1 A prescription from a TRICARE-authorized physician,
physician assistant, nurse practitioner, or nurse midwife is required
for coverage of a heavy-duty hospital grade breast pump.
4.1.2.2 Use of
a heavy-duty hospital grade breast pump may be covered for as long
as use of a heavy-duty hospital grade breast pump is determined
to be medically necessary and appropriate medical care.
4.1.2.3 If/when
a heavy-duty hospital grade breast pump is determined to no longer
be medically necessary and appropriate medical care, a manual or
standard electric breast pump may be covered.
4.1.2.4 Cost-shares, copays,
and deductibles do not apply to heavy-duty hospital
grade breast pumps and associated supplies for services rendered
on or after December 19, 2014.
4.2 Manual/Standard
Electric Breast Pumps And Supplies
4.2.1 Manual or standard electric
breast pumps and associated supplies are covered for services rendered
on or after December 19, 2014, the date of the FY 2015 NDAA.
4.2.2 One manual
(E0602) or one standard electric (E0603) breast pump may be covered
per birth event.
4.2.3 Standard power adapters, tubing
and tubing adaptors, locking rings, bottles, bottle caps, shield/splash
protectors, and storage bags used with the breast pump are covered
as necessary for up to 36 months post birth event.
4.2.4 Breast
pump kits are also covered. Pump kits, which are specific to each
breast pump manufacturer’s requirements, provide the necessary supplies/accessories
to allow expression of breast milk from both breasts simultaneously
(double-pumping). Up to two breast pump kits are covered per birth
event.
4.2.5 A prescription from a TRICARE-authorized physician,
physician assistant, nurse practitioner, or nurse midwife is required
for coverage of the breast pump. In addition, the prescription must,
at a minimum, indicate the type of breast pump prescribed (manual
or standard electric).
4.2.6 To be covered, the breast
pump and supplies must be obtained from a TRICARE-authorized provider,
supplier, or vendor. For manual or standard electric breast pumps
and associated supplies (includes breast pump kits), this includes
any civilian retail store or pharmacy (please reference
Chapter 11, Section 9.1, paragraph 2.2.1).
4.2.7 In the
event a beneficiary pays out-of-pocket for a covered breast pump
and/or supplies, the beneficiary may request reimbursement from
the appropriate contractor. To request reimbursement from the contractor,
the beneficiary must submit an approved and properly completed claim
form with a copy of the prescription for the breast pump and an
itemized receipt(s). An approved claim form is either a Department
of Defense Document (DD) Form 2642 (
http://www.dtic.mil/whs/directives/forms/eforms/dd2642.pdf)
or a Centers for Medicare and Medicaid Services (CMS) 1500 Claim
Form.
4.2.8 Cost-shares, copays,
and deductibles do not apply to manual or standard
electric breast pumps and supplies for services rendered on or after
December 19, 2014.
4.3 Breastfeeding/Lactation -
Counseling
4.3.1 Breastfeeding/Lactation counseling is generally
considered an expected component of good clinical practice. Therefore,
reimbursement of breastfeeding/lactation counseling rendered during
the inpatient maternity stay or an outpatient OB or well-child care
visit is included in the allowance for the primary service. However,
for services rendered on or after December 19, 2014, up to six individual
outpatient breastfeeding/lactation counseling sessions (Current
Procedural Terminology (CPT) procedure codes 99401-99404), per birth
event, may be covered. These counseling sessions are
in addition
to breastfeeding/lactation counseling that may be provided
during an inpatient maternity stay, outpatient OB visit, or well-child
visit. However, these additional counseling sessions are only covered
and separately reimbursed when
all of the following
are met:
• The
breastfeeding/lactation counseling is billed using one of the preventive
counseling CPT procedure codes 99401-99404; and
• Breastfeeding/Lactation
counseling is the only service being provided; and
• The breastfeeding/lactation
counseling is rendered by a TRICARE-authorized individual professional
provider (e.g., physician, physician assistant, nurse practitioner,
nurse midwife, or registered nurse), outpatient hospital, or clinic.
4.3.2 Cost-shares, copays,
and deductibles do not apply to covered breastfeeding/lactation counseling
sessions for services rendered on or after December 19, 2014.