When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
E0602 Breast pump, manual, any type
E0603 Breast pump, electric (AC and/or DC), any type
E0604 Breast pump, hospital grade, electric (AC and/or DC), any type
THE FOLLOWING CODES ARE USED TO REPRESENT BREAST PUMP SUPPLIES:
A4281 Tubing for breast pump, replacement
A4282 Adapter for breast pump, replacement
A4283 Cap for breast pump bottle, replacement
A4284 Breast shield and splash protector for use with breast pump, replacement
A4285 Polycarbonate bottle for use with breast pump, replacement
A4286 Locking ring for breast pump, replacement
Policy: 05.00.21t:Durable Medical Equipment (DME) and Consumable Medical Supplies
Policy: 05.00.44k:Repair and Replacement of Durable Medical Equipment (DME)
Policy: 05.00.48j:Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
Policy: 00.06.02y:Preventive Care Services (Independence)