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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyModa Health Breast Pump Coverage Policy | OpenPaye…
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    CurrentModa HealthPolicy N/A

    Breast Pumps

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    This policy governs Moda Health medical-necessity coverage for manual, electric, and hospital-grade breast pumps. Hospital-grade pump rental is covered only when specified clinical criteria, prescription, and contracted DME-provider requirements are met.

    Policy Summary
    PayerModa Health
    PolicyBreast Pumps
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSep 1, 2026
    Last ReviewAug 26, 2026
    Next Review DateN/A
    Key ActionSubmit chart notes documenting medical necessity and a physician order or prescription with the prior authorization request.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3Covered breast pump codes
    E0604Hospital-grade pump code
    2Prior-authorization documentation items
    Not coveredReplacement supplies

    Coverage Criteria

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Hospital-grade breast pump rental

    Hospital-grade breast pump rental is considered medically necessary when ALL of the following criteria are met:

    ALL requirements

    • Prior pump trial

      • A manual, battery-powered, or standard electric breast pump has been trialed and failed.

    • ONE qualifying indication

      • Infant or maternal separation

        • Prolonged separation or repeat hospitalization of either the infant or mother makes it impossible to breastfeed.

      • Infant medical condition or congenital anomaly

        • The infant has a medical condition, such as a respiratory, cardiac, or genetic condition, or a congenital anomaly, such as cleft palate, cleft lip, or another anomaly of the tongue, mouth, or pharynx, that prevents effective breastfeeding.

      • Maternal medical condition or structural anomaly

        • The mother has a medical condition or structural anomaly that prevents effective breastfeeding, including mastitis or breast abscess.

    • Prescription and supplier requirements

      • The member has a physician's prescription.
      • The hospital-grade breast pump rental is obtained from a contracted Durable Medical Equipment (DME) provider.

    Rental of a hospital-grade breast pump when requested for convenience is considered not medically necessary and is not covered under the medical-necessity criteria.

    Replacement breast-pump supplies are not covered, including replacement caps, nipples or bottle lids, locking rings, and polycarbonate bottles.

    Rental of a hospital-grade breast pump requested for convenience is considered not medically necessary. Coverage requires that the rental meet the applicable medical-necessity criteria rather than being requested solely for convenience.

    Covered HCPCS Codes

    Covered HCPCS CodesHCPCSCovered
    E0602Breast pump, manual, any type
    E0603Breast pump, electric (AC and/or DC), any type
    E0604Breast pump, hospital grade, electric (AC and /or DC), any type

    Provider Actions and Authorization Risks

    Prior Authorization

    Hospital-Grade Pump Authorization

    Prior authorization is required for rental of a hospital-grade breast pump (E0604). Submit the required documentation and ensure the pump is obtained through a contracted Durable Medical Equipment (DME) provider.

    • Prior authorization request must include medical-necessity chart notes.
    • Include a physician's order or prescription.
    • Rental must be obtained from a contracted DME provider.
    Step Therapy

    Document Trial and Failure

    Before hospital-grade pump rental is covered, document that a manual, battery-powered, or standard electric breast pump was trialed and failed. The request must also identify a qualifying clinical indication.

    • Prolonged separation or repeat hospitalization of the infant or mother that makes breastfeeding impossible.
    • An infant medical condition or congenital anomaly that prevents effective breastfeeding, including respiratory, cardiac, genetic, cleft palate, cleft lip, or other tongue, mouth, or pharyngeal anomalies.
    • A maternal medical condition or structural anomaly that prevents effective breastfeeding, including mastitis or breast abscess.
    Documentation Required

    Submit Medical-Necessity Chart Notes

    Include chart notes with the prior authorization request that identify the medical necessity of the hospital-grade breast pump and support the applicable qualifying indication.

    Documentation Required

    Submit Physician Order or Prescription

    Include the physician's order or prescription with the prior authorization request for hospital-grade pump rental.

    Denial Risk

    Hospital-Grade Pump Criteria Not Met

    Coverage is at risk when the required trial and failure of a manual, battery-powered, or standard electric pump is not documented, or when a qualifying medical indication and supporting documentation are absent.

    • Confirm the request documents the required pump trial and failure.
    • Confirm the request supports prolonged separation or repeat hospitalization, an infant condition or anomaly, or a maternal condition or structural anomaly preventing effective breastfeeding.
    Denial Risk

    Convenience Requests Are Not Covered

    A hospital-grade breast pump rental requested for convenience is considered not medically necessary and is not covered on that basis.

    Billing Rule

    Replacement Supplies Excluded

    Replacement breast-pump supplies are not covered.

    • Replacement cap, nipple, or lid for a breast-pump bottle.
    • Replacement locking ring.
    • Replacement polycarbonate bottle.

    Background

    Breastfeeding and human milk are described as normative standards for infant feeding and nutrition, with documented short- and long-term medical and neurodevelopmental benefits. A breast pump may allow milk expression when direct breastfeeding is not possible and may help maintain or increase milk supply or relieve engorgement.

    Definitions

    Breast Pump
    DefinitionA breast pump is a device that allows a person to express milk from their breast when it is not possible to breastfeed.
    UsesBreast pumps may help maintain or increase milk supply, relieve engorgement, and allow milk expression when breastfeeding is not possible.
    TypesBreast pumps may be manual, electric, or battery powered.

    Medical Necessity Determination

    Hospital-grade pump rental

    Hospital-grade breast pump rental is medically necessary when all specified clinical, prescription, and supplier requirements are met:

    ALL requirements

    • Prior pump trial

      • A manual, battery-powered, or standard electric breast pump has been trialed and failed.

    • ONE qualifying indication

      • Infant or maternal separation

        • Prolonged separation or repeat hospitalization of either the infant or mother makes it impossible to breastfeed.

      • Infant medical condition or congenital anomaly

        • The infant has a medical condition, such as a respiratory, cardiac, or genetic condition, or a congenital anomaly, such as cleft palate, cleft lip, or another anomaly of the tongue, mouth, or pharynx, that prevents effective breastfeeding.

      • Maternal medical condition or structural anomaly

        • The mother has a medical condition or structural anomaly that prevents effective breastfeeding, including mastitis or breast abscess.

    • Prescription and supplier requirements

      • The member has a physician's prescription.
      • The hospital-grade breast pump rental is obtained from a contracted Durable Medical Equipment (DME) provider.

    Rental and Purchase Rules

    Equipment / HCPCS codeCoverage rule
    Hospital-grade breast pump (E0604)Rental is covered when medical-necessity criteria are met, including a failed trial of a manual, battery-powered, or standard electric breast pump; a qualifying maternal or infant indication; a physician's prescription; and use of a contracted DME provider.

    Prior Authorization Documentation

    Documentation Required

    Submit medical-necessity chart notes

    Submit chart notes identifying the medical necessity of the equipment with the prior authorization request.

    Documentation Required

    Submit the physician order or prescription

    Submit documentation of a physician's order or prescription with the prior authorization request.

    Excluded Services and Supplies

    The following items are not covered: hospital-grade breast pump rental requested for convenience and replacement breast-pump supplies, including replacement caps, nipples or bottle lids, locking rings, and polycarbonate bottles.

    Policy Summary
    PayerModa Health
    PolicyBreast Pumps
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSep 1, 2026
    Last ReviewAug 26, 2026
    Next Review DateN/A
    Key ActionSubmit chart notes documenting medical necessity and a physician order or prescription with the prior authorization request.
    SourceLink
    On This Page
    Coverage CriteriaCovered HCPCS CodesProvider Actions and Authorization RisksBackgroundDefinitionsMedical Necessity DeterminationRental and Purchase RulesPrior Authorization DocumentationExcluded Services and Supplies