DESCRIPTION
Breast pumps are available in a variety of configurations, all of which are designed to pump human breast milk for short- or long-term storage. Some models are simple cylinders that interface with a plastic cone that fits over the areola. A syringe-type piston can then be manually retracted by the user to create and release suction on the nipple. The pumped milk drains by gravity into an attached container. The milk can be decanted into plastic bags for refrigerated storage or freezing. Electric models work by creating pulsating suction, usually by pneumatic action against a diaphragm. Hospital grade piston operated electric pumps are typically larger and heavier and therefore, are not as portable as a standard personal electric breast pump. Except for disposable plastic storage containers, components to all models are generally cleanable and reusable.
POLICY
Use of a hospital-grade breast pump is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
MEDICAL APPROPRIATENESS
A hospital-grade breast pump is considered medically appropriate for ANY ONE of the following:
For the period of time that a newborn is detained in the hospital after the mother is discharged.
Direct breastfeeding is not possible because of a separation due to the prolonged or repeat hospitalization of either the infant or the mother.
The infant has a medical condition or congenital anomaly that prevents effective breastfeeding.
The mother has a medical condition or anatomical anomaly that prevents effective breastfeeding.
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
SOURCES
American Academy of Pediatrics (AAP). (2022) Policy Statement: Breastfeeding and the use of human milk. Retrieved November 16, 2022 from https://www.publications.aap.org/pediatrics.
Becker, G. E., Smith, H. A., & Cooney, F. (2016). Methods of milk expression for lactating women. The Cochrane Database of Systematic Reviews, 9 (9), CD006170. Doi: 10.1002/14651858.CD006170.pub5. (Level 1 evidence)
Larkin, T., Kiehn, T., Murphy, P. K., & Uhryniak, J. (2013). Examining the use and outcomes of a new hospital-grade breast pump in exclusively pumping NICU mothers. Advances in Neonatal Care: Official Journal of the National Association of Neonatal Nurses, 13 (1), 75–82, doi: 10.1097/ANC.0b013e31827d4ce3. Abstract retrieved November 16, 2022 from PubMed database.
Martino, K., Wagner, M., Froh, E. B., Hanlon, A. L., & Spatz, D. L. (2015). Postdischarge breastfeeding outcomes of infants with complex anomalies that require surgery. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNN, 44 (3), 450-457, Doi: 10.1111/1552-6909.12568. Abstract retrieved November 16, 2022 from PubMed database.
Meier, P. P., Engstrom, J. L., Hurst, N. M., Ackerman, B., Allen, M., Motykowski, J. E., et al. (2008). A comparison of the efficiency, efficacy, comfort, and convenience of two hospital-grade electric breast pumps for mothers of very low birthweight infants. Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine, 3 (3), 141-150, doi: 10.1089/bfm.2007.0021. Abstract retrieved November 16, 2022 from PubMed database.
National Association of Neonatal Nurses (NANN). (2015, April). The use of human milk and breastfeeding in the neonatal intensive care unit. Position statement #3065. Retrieved November 17, 2022 from https://www.nann.org.
Renfrew, M. J., Craig, D., Dyson, L., McCormick, F., Rice, S., King, S. E., et al. (2009). Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis. Health Technology Assessment (Winchester, England), 13 (40), 1-iv, Doi: 10.3310/hta13400. (Level 1 evidence)
U. S. Food and Drug Administration. (2018, March). Consumer Products. Breast pumps. Retrieved November 16, 2022 from https://www.fda.gov/meical-devices/consumer-products/breast-pumps.
ORIGINAL EFFECTIVE DATE: 4/4/2023
MOST RECENT REVIEW DATE: 1/11/2024
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.