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    v1.0.28
    OpenPayerPolicy UpdatesObstetrics/GynecologyAlaska Medicaid Breast Pump Coverage & Prior Auth …
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    CurrentAlaska MedicaidPolicy N/A

    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.

    Policy Summary
    PayerAlaska Medicaid
    PolicyBreast Pumps
    Policy CodePolicy N/A
    Change TypeClarified dispensing timeframe and criteriareiterated prior authorization for hospital-grade pumps
    Effective DateN/A
    Next Review DateN/A
    Key ActionPrescribers must be actively enrolled in AK Medicaid and document that all coverage criteria are met prior to issuing a prescription; obtain service authorization before dispensing hospital-grade pump E0604.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes

    3HCPCS codes referenced
    5Example ICD-10 codes listed
    1/3yrsQuantity limit for personal pumps (E0602/E0603)

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    E0604Prior auth required

    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

    • Personal pump quantity limit: Manual breast pump (E0602) and electric breast pump (E0603) may be dispensed at a quantity of no more than 1 every 3 years1 every 3 years

      Applies to E0602 and E0603

    • 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

    Covered HCPCS - Manual and Electric Breast PumpsHCPCSCovered
    E0602Manual breast pump
    E0603Electric breast pump (personal use)
    Hospital-grade Breast Pump - Prior Authorization RequiredHCPCSCovered
    E0604Breast pump, hospital grade (requires approved service authorization prior to dispensing)
    Example Diagnosis Codes to Support Medical Necessity (examples only)ICD-10
    Z3A.32Weeks of gestation 32 weeks
    Z3A.33Weeks of gestation 33 weeks
    Z37.0Single live birth
    Z39.1Encounter for care and examination of lactating mother
    P92.5Neonatal difficulty in feeding at the breast

    Provider Actions & Billing Rules

    Prior Authorization

    Service authorization for hospital-grade pump

    Obtain an approved service authorization prior to dispensing a hospital-grade breast pump (E0604). Authorization must be secured before dispensing the device.

    • Affected code: E0604
    • Authorization must be obtained prior to dispensing
    Documentation Required

    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).

    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

    Policy Summary
    PayerAlaska Medicaid
    PolicyBreast Pumps
    Policy CodePolicy N/A
    Change TypeClarified dispensing timeframe and criteriareiterated prior authorization for hospital-grade pumps
    Effective DateN/A
    Next Review DateN/A
    Key ActionPrescribers must be actively enrolled in AK Medicaid and document that all coverage criteria are met prior to issuing a prescription; obtain service authorization before dispensing hospital-grade pump E0604.
    SourceLink
    On This Page
    Coverage SummaryMedical Necessity CriteriaCodingProvider Actions & Billing RulesBackgroundRevision History
    Billing Rule

    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.

    Denial Risk

    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.