CurrentEmblemHealthPolicy MG.MM.ME.71bC

Pasteurized Donor Human Breast Milk (PDHM)

This policy defines medical necessity criteria, coverage conditions, and billing guidance for pasteurized donor human breast milk for infants, and applies to EmblemHealth members (New York State context).

Policy Summary

PayerEmblemHealth

PolicyPasteurized Donor Human Breast Milk (PDHM)

Policy CodePolicy MG.MM.ME.71bC

Change TypeReinstated / Outpatient coverage added

Effective Date

Next Review DateOct 10, 2025

Key ActionSubmit prior authorization with a licensed practitioner order and clinical evidence that the infant meets medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

Reinstated commensurate with New York State mandate which removes inpatient setting restriction and established outpatient coverage effective Jan. 1, 2025.

Previously retired policy status was reversed (policy had been retired July 14, 2023).

<1500 gBirth weight threshold

T2101Procedure code

Jan 1, 2025Outpatient coverage

NY lawSupporting mandate

Coverage and Medical Necessity Criteria

Policy Summary

PayerEmblemHealth

PolicyPasteurized Donor Human Breast Milk (PDHM)

Policy CodePolicy MG.MM.ME.71bC

Change TypeReinstated / Outpatient coverage added

Effective Date

Next Review DateOct 10, 2025

Key ActionSubmit prior authorization with a licensed practitioner order and clinical evidence that the infant meets medical necessity criteria.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medical Necessity Criteria

Covered when ALL of the following are met:

Primary medical necessity

Additional conditions: One or more of: medically or physically unable to receive maternal breast milk or participate in breast feeding; unable to participate in breast feeding despite optimal lactation support; maternal breast milk unsuitable for consumption due to presence of certain substances or disease; mother medically or physically unable to produce maternal breast milk or produces insufficient quantities.one or more conditions met
Outpatient coverage effective Jan. 1, 2025

Coverage requires an order from a licensed medical practitioner. PDHM will be considered only when a licensed practitioner has issued the order for the infant; absence of a licensed practitioner order is an implied exclusion.

PDHM is not indicated for infants who do not meet the primary criteria of documented birth weight < 1500 grams or a congenital/acquired condition placing the infant at high risk for NEC and/or infection, unless one or more of the additional conditions apply. Covered additional conditions include: medically or physically unable to receive maternal breast milk or participate in breastfeeding; unable to participate despite optimal lactation support; maternal breast milk unsuitable due to substances or disease; or mother medically/physically unable to produce sufficient milk. An order must be issued by a licensed medical practitioner for coverage to be considered.

Provider Responsibilities, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required. The treating physician or primary care provider must submit clinical evidence that the patient meets the criteria for Pasteurized Donor Human Breast Milk (PDHM) and a licensed practitioner order. Without this documentation, EmblemHealth will not be able to properly review the request for prior authorization.

Submit clinical evidence demonstrating the infant meets guideline criteria (e.g., birth weight <1500 g, congenital/acquired high-risk conditions for NEC/infection, inability to receive maternal milk despite lactation support).
Provide a licensed medical practitioner order for PDHM.
Include documentation of why maternal breast milk is unavailable or unsuitable (e.g., maternal medical condition, insufficient production, presence of contraindicating substances/diseases).
Outpatient PDHM coverage effective Jan. 1, 2025 — ensure date-specific coverage applicability is noted on the request.

Step Therapy

Step Therapy Not Applicable

Step therapy is not applicable to PDHM. Coverage is determined by meeting the specified medical necessity criteria rather than sequencing through alternative treatments.

Documentation Required

Order and Clinical Documentation

An order from a licensed practitioner and supporting clinical documentation must accompany the prior authorization request. Examples of required documentation include: infant birth weight and gestational age, diagnosis and clinical indication (including conditions placing the infant at high risk for NEC or infection), documentation of attempts at lactation support and reason maternal milk is unavailable or unsuitable, and the licensed practitioner’s signed order specifying PDHM (and any fortifiers if indicated).

Infant clinical data: birth weight (grams), gestational age, relevant diagnoses.
Clinical rationale: documentation showing high risk for NEC/infection or inability to receive maternal milk.
Lactation support records: evidence of optimal lactation support and reason for failure, if applicable.
Practitioner order: signed order from a licensed medical practitioner specifying PDHM and fortifiers if required.

Denial Risk

Documentation Required for Review

Failure to submit the required clinical evidence and licensed practitioner order may prevent review and result in denial of the request for PDHM. EmblemHealth will not be able to properly review prior authorization requests lacking sufficient documentation.

Incomplete or missing documentation may result in denial or delay of prior authorization.
Ensure all requested clinical records and signed orders are included at submission to avoid administrative denials.

Clinical Background

Pasteurized donor human breast milk (PDHM) is used to reduce the risk of necrotizing enterocolitis (NEC) and infection in infants who are at high risk or who have very low birth weight. The policy specifies PDHM (which may include fortifiers as medically indicated) as medically necessary for infants with a documented birth weight of < 1500 grams or with congenital or acquired conditions that place them at elevated risk for NEC and/or infection; coverage applies when at least one of the listed additional conditions (for example, inability to receive maternal milk or insufficient maternal milk despite lactation support) is present.

OpenPayer

Pasteurized Donor Human Breast Milk (PDHM)

Coverage and Medical Necessity Criteria

Procedure Codes and Key Coding Thresholds

Provider Responsibilities, Authorization, and Documentation

Clinical Background

Definitions