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To better serve the development needs of premature infants, an update issued Aug. 8, 2005, to TRICARE Policy Manual 6010.54-M, Aug. 1, 2002, covers heavy-duty hospital-grade (E0604) electric breast pumps (including services and supplies related to the use of the pump) for mothers of premature infants.
Premature infants miss some or all of the crucial transfer of immunoglobulins from their mothers during the last several weeks of gestation and suffer from underdeveloped immune systems. While maternal immunoglobulins are present in breast milk, many premature infants cannot breastfeed successfully. Using an electric breast pump ensures that these infants receive an adequate supply of breast milk to address their immunological challenges.
Under the policy, a hospital-grade electric breast pump is covered while the premature infant remains hospitalized during the immediate post-partum period, as defined by ICD-9 codes 765.0, 765.1, or 765.21–765.28. Electric breast pumps may also be covered after the premature infant is discharged from the hospital with a physician-documented medical reason consistent with the above ICD-9 codes, such as the inability to breastfeed. This documentation is also required for premature infants delivered in non-hospital settings. Hospital-grade electric breast pumps are reimbursable as durable medical equipment after the hospital discharge.
Breast pumps of any type when used for reasons of personal convenience (e.g., to facilitate a mother’s return to work) are excluded even if prescribed by a physician. Manual breast pumps (E0602) and basic (non-hospital grade) electric breast pumps (E0603) are also excluded.
Although no prior authorization is needed, a physician’s prescription is required to obtain a breast pump. If the breast pump is not considered medically necessary upon review of the claim, the claim will be denied.
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