CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

breast_pump_medical_necessity_criteria

Defines medical necessity criteria and billing code for hospital-grade electric breast pumps (E0604) under Medicare Advantage and Commercial products; distinguishes from manual/electric pumps covered under preventive services. Prior authorization recommended via web tool for participating providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policybreast_pump_medical_necessity_criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is recommended via the online/web-based tool and providers must document the clinical reason that meets one of the medical necessity criteria to support DME benefit coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

1Covered HCPCS code

2Medical necessity criteria (OR logic)

4Provider Updates listed (years)

Coverage Summary

This policy covers hospital-grade electric breast pumps (E0604) under the durable medical equipment benefit when medical necessity criteria are met. It distinguishes these devices from manual and consumer electric pumps, which are addressed under the Preventive Services for Commercial members. Prior authorization is recommended for participating providers via the online/web-based tool.

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Surface quick facts

Benefit applicabilityApplies to Medicare Advantage Plans and Commercial Products under the member's durable medical equipment benefit when medical criteria are met

Covered HCPCS code count1 HCPCS code (E0604: Breast pump, Hospital grade, electric)

Coverage stanceCovered with criteria — hospital-grade electric breast pump is medically necessary when at least one specified medical criterion is met (involuntary separation >24 hours or infant medical/congenital condition interfering with breastfeeding)

Prior authorizationPrior authorization is recommended and obtained via the online/web-based tool for participating providers

Rental noteIf rented, rental period is one month per policy note

Medical Necessity Criteria

Medical Necessity for Hospital-Grade Electric Breast Pump

Hospital-grade electric breast pump is considered medically necessary when ONE of the following criteria is met:

Medical necessity criteria

Involuntary separation: There is an involuntary separation of an infant from its mother for more than 24 hours due to illness or injury of the infant.
Infant medical or congenital condition: Breast-feeding infant has a medical or congenital condition that interferes with breast-feeding (examples: respiratory, cardiac, genetic conditions; congenital conditions such as cleft palate).

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title?:"Medical Necessity for Hospital-Grade Electric Breast Pump"

Benefit Applicability

Applicability

Benefit applicability: Coverage applies to Medicare Advantage Plans and Commercial Products under the member's durable medical equipment benefit when the medical criteria above have been met.

Provider Actions

Prior Authorization

Prior authorization recommended

Prior authorization is recommended and obtained via the online/web-based tool for participating providers.

Affected code: E0604
Obtain via participating providers web-based tool

Documentation Required

Document medical reason for pump

Provider must document the clinical reason that meets one of the medical necessity criteria (involuntary separation >24 hours or infant medical/congenital condition interfering with breastfeeding) to support DME benefit coverage.

Affected code: E0604
Examples: involuntary separation >24 hours; infant medical/congenital conditions interfering with breastfeeding

Billing Rule

Rental period

If rented, note that rental is a one month period per policy note.

Applies to E0604

Definitions & Background

Hospital-grade electric breast pumps are devices specifically designed for reuse and sterilization and are not sold commercially. They differ from manual and consumer electric pumps, which are typically not designed for reuse and are intended for mothers with normal infants (for example, those who are working or traveling) and are addressed under preventive services. Professional guidance recognizes clinical benefits of breastfeeding, including recommendations to exclusively breastfeed expressed human milk for the first six months and continued breastfeeding thereafter; hospital-grade pumps support those clinical goals when medical circumstances interfere with direct breastfeeding. The HCPCS code for coverage when criteria are met is E0604 (Breast pump, Hospital grade, electric) (rental noted as a one month period).

Term	Definition
Hospital-grade electric breast pump	A breast pump designed for reuse (sterilizable) and not sold commercially; intended for hospital use.
Involuntary separation	Separation of an infant from its mother for more than 24 hours due to illness or injury of the infant.

Revision History

Published April 2021policy_publishedLatest

Provider Update listing indicates policy published in April 2021.

Published May 2020policy_published

Provider Update listing indicates policy published in May 2020.

Published August 2019policy_published

Provider Update listing indicates policy published in August 2019.

Published 2018 (August)policy_published

Provider Update listing indicates policy published in August 2018.

Published 2017 (November)policy_published

Provider Update listing indicates policy published in November 2017.

Published 2016 (Nov/Dec)policy_published

Provider Update listing indicates policy published in November/December 2016.