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 The supply limitations
established for the manual and standard electric breast pumps in
paragraphs 4.2 through
4.2.9 apply
to heavy-duty hospital grade pumps.
4.1.2.5 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 For
dates of service prior to July 5, 2018, 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). For dates of service prior to July 5, 2018, up to
two breast pump kits are covered per birth event. Effective July
5, 2018, one breast pump kit is covered per birth event, but may
not be separately reimbursed. See
paragraph 5.5.
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 Effective for
dates of service on or after July 5, 2018, only the following replacement supplies
are available without an additional prescription:
• Bottles: Two
replacement bottles and caps/locking rings every 12 months following
a birth event;
• Power Adapters: One power adapter per birth
event (Healthcare Common Procedure Code System (HCPCS)
A4282), and not within the first 12 months following
purchase;
• Valves: Twelve valves/membranes for each
12 months period following a birth event;
• One set (2)
of flanges/breast shields per birth event;
• One set of tubing
per birth event;
• Ninety breast milk bags every 30 days following
the birth event.
4.2.8 Effective
July 5, 2018, two sets (2) of nipple shields and one Supplemental
Nursing System (SNS) per birth event may be covered when prescribed
by a TRICARE-authorized provider.
4.2.9 Effective July 5, 2018, additional
replacement supplies, in addition to those detailed in
paragraphs 4.2.7 and
4.2.8,
may be covered when a new prescription from an authorized individual professional
provider is obtained, describing the specific supplies required.
Only those replacement supplies in excess of the limits described
in
paragraphs 4.2.7 and
4.2.8,
which are essential for breast feeding and are accompanied by a
new prescription from a TRICARE-authorized individual professional provider,
shall be reimbursed.
4.2.10 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. Effective July 5, 2018, limitations on the maximum amount
of reimbursement available for beneficiary-purchased breastfeeding
supplies may result in out-of-pocket expenses. The contractor shall
ensure appropriate beneficiary education regarding the maximum amount
of reimbursement available under the program as detailed in the
TRICARE Reimbursement Manual (TRM),
Chapter 1, Addendum D and in this section.
4.2.11 Cost-shares,
copays, and deductibles do not apply to manual or standard electric
breast pumps and supplies for covered services provided 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.