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TRICARE Policy Manual 6010.60-M, April 1, 2015
Other Services
Chapter 8
Section 2.6
Breast Pumps, Breast Pump Supplies, And Breastfeeding Counseling
Issue Date:  August 8, 2005
Authority:  32 CFR 199.4(d)(1) and (f)(12)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-25, June 15, 2018
1.0  CPT Procedure Codes
99401 - 99404
2.0  HCPCS PROCEDURE CODES
Level II Codes E0604, A4281 - A4286
3.0  Background
3.1  Effective August 8, 2005, TRICARE began covering heavy-duty hospital grade breast pumps and associated supplies for mothers of premature infants. However, heavy-duty hospital grade breast pumps for other conditions, as well as manual and standard electric breast pumps, were excluded from coverage.
3.2  On December 19, 2014, the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2015 was signed into effect. Section 706 of this Law allows expanded coverage of breast pumps and supplies, as well as coverage of breastfeeding counseling. Therefore, effective for services rendered on or after December 19, 2014, breast pumps (including manual and standard electric breast pumps), breast pump supplies, and breastfeeding counseling obtained in accordance with this policy are covered. This coverage is extended to all pregnant TRICARE beneficiaries, as well as for a female beneficiary who legally adopts an infant and intends to personally breastfeed the adopted infant. This will subsequently be referred to in this policy as a “birth event”.
3.3  In general, the equipment, supplies, and counseling authorized by Section 706 of the FY 2015 NDAA are considered to be preventive. Therefore, in accordance with the authority provided by the FY 2009 NDAA, Section 711, cost-shares, copays, and deductibles are waived for breast pumps, breast pump supplies, and breastfeeding counseling services rendered on or after December 19, 2014.
4.0  POLICY
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.
5.0  EXCLUSIONS
5.1  The following products associated with breast pump use are specifically excluded:
•  Breast pump batteries, battery-powered adapters, and battery packs;
•  Regular “baby bottles” (Bottles not specific to pump operation), including associated nipples, caps, and lids;
•  Travel bags and other similar carrying accessories;
•  Breast pump cleaning supplies;
•  Baby weight scales;
•  Garments and other products that allow hands-free pump operation;
•  Ice packs, labels, labeling lids, and other similar products;
•  Nursing bras, bra pads, breast shells, and other similar products; and
•  Over-the-counter creams, ointments, and other products that relieve breastfeeding related symptoms or conditions of the breasts or nipples.
5.2  Individual outpatient breastfeeding/lactation counseling sessions rendered by an individual professional provider, outpatient hospital or clinic that is not TRICARE-authorized.
6.0  Effective Dates
6.1  The effective date for coverage of heavy-duty hospital grade breast pumps and supplies is August 8, 2005.
6.2  The effective date for coverage of a manual or standard electric breast pump and associated supplies, and counseling services covered under this policy is December 19, 2014.
6.3  The effective date for elimination of cost-shares, copays, and deductibles for the equipment, supplies, and services covered under this policy is December 19, 2014.
- END -

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