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Breast Pumps
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Defines Alaska Medicaid coverage criteria and billing rules for manual (E0602), electric (E0603) and hospital-grade (E0604) breast pumps dispensed by DMEPOS providers, including eligibility timing, documentation and authorization requirements.
No material clinical or coverage changes
Coverage Summary
Covered with criteria: Alaska Medicaid covers manual (E0602) and electric (E0603) breast pumps when prescribed and dispensed by DMEPOS providers and when all coverage criteria are met. Key thresholds: member is at least 32 weeks gestation or has recently given birth (child age ≤ 24 months), and personal pumps (E0602/E0603) are limited to 1 every 3 years. DME must be prescribed by an actively enrolled Alaska Medicaid prescriber and medical necessity must be documented in the medical record prior to issuing a prescription.
Medical Necessity Criteria
Coverage Criteria (All must be met)
Covered when ALL of the following are met:
- Clinical and capability criteria: Member is at a minimum of 32 weeks gestation, or has recently given birth, or their child is 24 months of age or younger>= 32 weeks; child <= 24 months
- Milk production potential: Potential exists for adequate milk production
- Intention to provide breast milk: Member plans to provide breast milk to their infant(s)
- Training capability: Member is capable of being trained to use the breast pump
- Prescriber enrollment and documentation: DME is prescribed by an actively enrolled Alaska Medicaid physician, physician assistant, or advanced practice registered nurse acting within the scope of that person's licensePrescriber must be actively enrolled in AK Medicaid
Prescribers must ensure coverage criteria is met and documented in the medical record prior to issuing a prescription
- Diagnosis code on prescription: Prescription must include an appropriate diagnosis code demonstrating coverage timeframe (examples: Z3A.32, Z3A.33, Z37.0, Z39.1, P92.5)Diagnosis codes are examples only
DMEPOS providers must ensure prescription orders meet coverage criteria #1 by documenting an appropriate diagnosis code on the prescription
Quantity and Dispensing Frequency
- Hospital-grade authorization: Hospital grade breast pump (E0604) requires an approved service authorization prior to dispensingService authorization required
An approved service authorization is required prior to dispensing E0604
Coding
| E0604 | Breast pump, hospital grade (requires approved service authorization prior to dispensing) |
| Z3A.32 | Weeks of gestation 32 weeks |
| Z3A.33 | Weeks of gestation 33 weeks |
| Z37.0 | Single live birth |
| Z39.1 | Encounter for care and examination of lactating mother |
| P92.5 | Neonatal difficulty in feeding at the breast |
Provider Actions & Billing Rules
Prescriber documentation and enrollment
Prescriber must be actively enrolled in Alaska Medicaid and document in the medical record that all coverage criteria are met prior to issuing a prescription. Prescription must include an appropriate diagnosis code demonstrating the applicable timeframe (examples include Z3A.32, Z3A.33, Z37.0, Z39.1, P92.5).
Date of service and shipping rules
The date of service on the claim should be the date the member received the breast pump. If a supplier uses a delivery/shipping service, the supplier may use the shipping date (for example, the date the delivery label is created, the date the item is retrieved for delivery, or the date of delivery) as the date of service. At no time should the date of service be prior to 32 weeks gestation without first obtaining a service authorization.
Claims before 32 weeks gestation
Claims with a date of service prior to 32 weeks gestation may be denied unless a service authorization is obtained first.
Background
Background: Per 7 AAC 120.200, coverage of DME (including breast pumps) requires a prescription by an actively enrolled Alaska Medicaid physician, physician assistant, or advanced practice registered nurse and documentation of medical necessity in the medical record. Alaska Medicaid clarified the dispensing timeframe and coverage criteria for manual (E0602) and electric (E0603) pumps, expanded the billing timeframe allowing these pumps to be dispensed at a quantity of no more than 1 every 3 years, and reiterated that an approved service authorization is required prior to dispensing a hospital-grade breast pump (E0604). The agency also clarified date-of-service rules when items are shipped and noted claims prior to 32 weeks gestation may be denied without prior authorization.
Definitions: DMEPOS — durable medical equipment or prosthetics and orthotics providers.
Revision History
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