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 NDAA FY 2015.
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).
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) code
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 calendar 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.
4.2.11 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.
4.2.12 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) 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
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.