Aetna considers rental of a reusable breast pump medically necessary durable medical equipment (DME) when either of the following criteria is met:
For the period of time that a newborn is detained in the hospital after the mother is discharged; breast pump rental is not considered medically necessary once the newborn is discharged; or
For babies who have congenital disorders that interfere with feeding, a breast pump is considered medically necessary for up to 12 months of age.
Aetna does not cover breast pump purchase under standard Aetna benefit plans that are not currently subject to Department of Health and Human Services (DHHS) requirements for coverage of breast pumps. Non-reusable manual or electric breast pumps that are available commercially are not considered by Aetna to fall within the standard contractual definition of durable medical equipment in that they are normally of use in the absence of illness or injury.
Note: The following policy applies to new health plans and non-grandfathered plans that are currently subject to DHHS requirements for coverage of breast pumps, with coverage beginning in the first plan year that begins on or after August 1, 2012 (please check benefit plan descriptions):
Aetna considers purchase of a manual or standard electric breast pump medically necessary during pregnancy or at any time following delivery for breastfeeding.
Aetna considers purchase of a manual or standard electric breast pump medically necessary for women who plan to breastfeed an adopted infant when the above listed criteria are met.
Aetna considers rental of a heavy duty electrical (hospital grade) breast pump medically necessary for the period of time that a newborn is detained in the hospital.
For women using a breast pump from a prior pregnancy, a new set of breast pump supplies is considered medically necessary with each subsequent pregnancy for initiation or continuation of breastfeeding during pregnancy or following delivery.
A replacement manual breast pump is considered medically necessary for each subsequent pregnany, for breastfeeding during pregnancy or following delivery.
A replacement standard electrical breast pump is considered medically necessary for subsequent pregnancies, for breastfeeding during pregnancy or following delivery, for members who have not received a standard electric breast pump within the previous three years or if the intial electric breast pump is broken and out of warranty.
Aetna considers purchase of heavy duty electrical (hospital grade) breast pumps not medically necessary.
Breast-fed infants have a lower risk of diarrhea and otitis media than bottle-fed infants during the first year of life. For premature infants, breast milk helps prevent infections, speeds recovery from respiratory distress syndrome, increases weight gain, protects against retinopathy, and facilitates cognitive and visual development.
Aetna considers breast pump rental medically necessary for infants while they are detained in the hospital. Breast pumps used in the hospital are specifically designed for reuse (sterilizable) and are not sold commercially.
By contrast, the manual and electric breast pumps that are available commercially are not designed for reuse, and are most commonly sold to mothers with normal infants who are working, traveling, or for other reasons not always home to breast-feed the baby. Standard electric breast pumps or manual breast pumps may be necessary to initiate breast feeding in the postpartum period, within the first eight weeks following delivery. Manual breast pumps are sufficient for continuation of breastfeeding following the postpartum period. Current recommendations from the American Academy of Pediatrics are to continue breastfeeding of infants through one year of age.
Women may be able to breastfeed adopted infants through induced lactation. The process involves nipple stimulation with use of an electric breast pump beginning about two months before the adoptive mother expects to begin breast-feeding. In addition, hormonal therapy, such as supplemental estrogen or progesterone, may be prescribed to mimic the effects of pregnancy. Typically, hormone therapy for induced lactation is discontinued shortly before breast-feeding begins. At that point, the infant's suckling is thought to stimulate and maintain milk production.
Authorized under provisions of the Patient Protection and Affordable Care Act, the U.S. Department of Health and Human Services (DHHS) released health plan coverage guidelines, developed by a committee of the Institute of Medicine, that require health insurance plans to cover breast pumps and certain other women's preventive services. New health plans and non-grandfathered plans and issuers are required to provide coverage consistent with these guidelines in the first plan year (in the individual market, policy year) that begins on or after August 1, 2012.
CPT Codes / HCPCS Codes / ICD-9 Codes
HCPCS codes covered if selection criteria are met:
A4281 - A4286
Breast pump supplies
Breast pump, manual, any type
Breast pump, electric (AC and/or DC), any type
Breast pump, hospital grade, electric (AC and/or DC), any type
ICD-9 codes covered if selection criteria are met:
630 - 679.14
Complications of pregnancy, childbirth and the puerperium
749.00 - 749.25
Cleft palate and cleft lip
750.0 - 750.19
Tongue tie and other anomalies of tongue
750.21 - 750.29
Other specified anomalies of mouth and pharynx
V22.0 - V22.2
Supervision of normal pregnancy
V23.0 - V23.9
Supervision of high risk pregnancy
V24.0 - V24.2
Postpartum care and examination
The above policy is based on the following references:
American Academy of Pediatrics (AAP). Human milk. In: 2006 Red Book: Report of the Committee on Infectious Diseases. 26th ed. LK Pickering, CJ Baker, SS Long, JA McMillan, eds. Elk Grove Village, IL: AAP; 2006:123-130.
Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first six months of life. J Pediatr. 1995;126(2):191-197.
Bier JB, Ferguson A, Anderson L, et al. Breast-feeding of very low birth weight infants. J Pediatr. 1993;123(5):773-778.
Dewey KG, Heinig MJ, Nommsen-Rivers LA. Differences in morbidity between breast-fed and formula-fed infants. J Pediatr. 1995;126(5 Pt 1):696-702.
Hambidge KM, Krebs NF. Nutrition & feeding. In: Handbook of Pediatrics. 18th ed. GB Merenstein, D Kaplan, AA Rosenberg, eds. Stamford, CT: Appleton & Lange; 1997:50-51.
Anderson JW, Johnstone BM, Remley DT. Breast-feeding and cognitive development: A meta-analysis. Am J Clin Nutr. 1999;70(4):525-535.
Birch E, Birch D, Hoffman D, et al. Breast-feeding and optimal visual development. J Pediatr Ophthalmol Strabismus. 1993;30(1):33-38.
Hender K. Infant formula compared to breast milk for the prevention of allergies in neonates. Evidence Centre Critical Appraisal. Clayton, VIC: Centre for Clinical Effectiveness (CCE); 2001.
Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2002;(1):CD003517.
Quigley MA, Henderson G, Anthony MY, McGuire W. Formula milk versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2007;(4):CD002971.
Henderson G, Anthony MY, McGuire W. Formula milk versus maternal breast milk for feeding preterm or low birth weight infants. Cochane Database Syst Rev. 2007;(4):CD002972.
Henderson G, Fahey T, McGuire W. Nutrient-enriched formula milk versus human breast milk for preterm infants following hospital discharge. Cochrane Database Syst Rev. 2007;(4):CD004862.
Hayes DK, Prince CB, Espinueva V, et al. Comparison of manual and electric breast pumps among WIC women returning to work or school in Hawaii. Breastfeed Med. 2008;3(1):3-10.
Becker GE, McCormick FM, Renfrew MJ. Methods of milk expression for lactating women. Cochrane Database Syst Rev. 2008;(4):CD006170.
Ohyama M, Watabe H, Hayasaka Y. Manual expression and electric breast pumping in the first 48 h after delivery. Pediatr Int. 2010;52(1):39-43.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.