Policy Statement No.
2003-04 Rental of Hospital Grade Electric Breast Pumps
The following policy
statement is developed to clarify the Department’s policy regarding the rental
of hospital grade electric breast pumps. Please distribute this policy to
Medi-Cal Field Offices as
appropriate.
A.
POLICY
The rental of a hospital
grade electric breast pump is a benefit under the Medi-Cal Program for
pregnant and postpartum women, in accordance with Title 22, California Code of
Regulations (CCR), Sections 51321 and 51521. Welfare and Institutions Code
(W&I) Section 14132 specifies the services available under the Medi-Cal
Program. Hospital-grade electric breast pumps are a type of durable medical
equipment (DME), as defined in Title 22, CCR, Section 51160 and itemized in
Title 22, CCR, Section 51521. In subsection (m), DME is included as a benefit
subject to prior authorization. Title 22, CCR, Section 51321(a) specifies the
information that must be provided by a physician when prescribing DME; and
subsection (b) requires authorization when the cumulative cost of renting DME
items within a group exceeds $50.00 in a 15-month period.
Eligibility:
Prior authorization shall
be based upon medical necessity substantiated by documentation submitted with
the Treatment Authorization Request (TAR). The outpatient rental use can be
granted to either the mother or infant.
- A
mother who is either restricted or eligible to receive full-scope services
and who’s infant is up to one year of age.
- A
mother who is not full-scope eligible, and who’s infant is a Medi-Cal
beneficiary up to one year of age.
Time limitations:
TARs shall be authorized in
increments not to exceed six months. The estimated length of time cannot
exceed the maximum estimated allowable purchase price of the hospital grade
pump (i.e., $500.00) as stated under Title 22, CCR, Section 51321.
Medical criteria:
Rental of the
hospital-grade electric breast pump shall be authorized when direct nursing at
the breast is not established during the neonatal period (the period
immediately succeeding birth and continuing through the first 28 days of
life), and the treating physician submits documentation of any of the
following medical conditions:
- The
mother has been discharged from the hospital, but continues to be treated
for postpartum complications that preclude direct nursing at the breast.
- The
infant continues to be hospitalized for a neonatal illness and/or
prematurity, and the mother is no longer an inpatient.
- The
infant has a congenital neuromotor or oral dysfunction, or other congenital
or neonatal acquired condition that precludes effective direct nursing at
the breast.
Rental of a hospital-grade
electric breast pump shall be authorized when direct nursing at the breast is
established during the neonatal period, (The period immediately succeeding
birth and continuing through the first 28 days of life) when the treating
physician submits documentation that a minimum one week prior trial of an
over-the-counter electric breast pump failed to meet the mother’s or infant’s
medical needs and any of the following medical conditions exists:
- The
mother has a medical condition that requires treatment of her breast milk
before infant feeding.
- The
mother is receiving chemotherapy or other therapy with pharmaceutical agents
that render her breast milk unsuitable for infant feeding during therapy.
- The
infant developed a medical condition or requires hospitalization that
precludes direct nursing at the breast on a regular basis.
The TAR should include the
following when renting a hospital-grade electric breast pump when direct
nursing at the breast has been established during the neonatal period.
- A
written prescription from the physician treating the qualifying medical
condition(s) listed above.
- A
detailed summary of the qualifying medical condition(s) including diagnosis
and prognosis, and the expected length of need for the hospital-grade
electric breast pump.
- The
infant’s age and birth date.
When a minimum one-week
prior trial is required, the treating physician’s statement is needed to
describe why the personal grade electric pump failed to meet the medical needs
of the mother or infant.
B.
RATIONALE
Hospital-grade pumps are of
a sturdy mechanical quality used by hospitals, and are relatively large, heavy
and powerful. They offer enhanced suction strength and cycling for mothers
and infants who medically need these features. Consequently, the Department
has identified certain circumstances in which rental of a “hospital grade”
electric breast pump is medically necessary, such as maternal delivery
complications, prolonged infant impairment, and hospitalizations.
Failure to clarify a breast
pump policy would likely result in inconsistent decisions among Medi-Cal
consultants in field offices and could result in approval of services for some
patients and denial for others with the same or similar medical needs. In
other words, all Medi-Cal eligible beneficiaries would not be able to readily
access the available hospital grade electric breast pump benefit because of
varied policy interpretations. This policy would enable Medi-Cal consultants
to determine whether to approve TARS for the rental of hospital-grade electric
breast pumps.
Please note, the above
policy language is within a proposed Manual of Criteria regulatory packet that
is currently “On Hold” within the Office of Regulations. This packet
identified as R-13-00 will not be processed at this time because of other
regulatory priorities for completion. There is no timeline for approval of
R-13-00.
If there are any questions,
please contact, Mary Lamar-Wiley, Acting Chief of the
Medi-Cal Benefits Branch
at, 657-1460.
BIBLIOGRAPHY
-
American Academy of Pediatrics,
“Breastfeeding and the Use of Human Milk,” December 1997: 1035-1039.
Online at
http://www.aap.org/policy/re9729.html. Accessed July 30, 2001.
- American Academy of
Pediatrics, “The Transfer of Drugs and Other Chemicals Into Human etc. (PULL
LIST FROM MOC)
-
United States Department of Health and
Human Services (DHHS), Office of Women’s Health, DHHS Blueprint for Action
on Breastfeeding,” October 25, 2000. Online at
http://www.4woman.gov/breastfeeding/index.htm. Accessed July 24, 2001.
-
American Academy of Pediatrics, “A Woman’s
Guide to Breastfeeding,” 2001. Online. Online at
http://www.aap.org/family/brstquid.htm. Accessed
August 14, 2001
