Highmark Commercial Medical Policy - Pennsylvania

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Medical Policy: E-37-017
Topic: Electric Breast Pumps
Section: Durable Medical Equipment
Effective Date: July 1, 2013
Issue Date: April 30, 2018
Last Reviewed: March 2018

A breast pump is a device used to extract milk from the breast of a lactating mother for infant feeding when the mother cannot be present at feeding time or when the infant is too sick or too weak to suck.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Rental of an electric breast pump is eligible for reimbursement when ANY ONE of these criteria is met:

  • A breast pump is covered for the period of time that a newborn is detained in the hospital after the mother is discharged. Once the newborn is discharged, the breast pump will no longer be covered; or
  • A breast pump will be covered for babies who have congenital anomalies that interfere with feeding. Rental of the breast pump will be covered for the first month after the baby is discharged from the hospital. When a breast pump is utilized for longer than this specified time, its medical necessity should be determined on an individual consideration basis. The purchase of a breast pump will be covered in cases where purchase of the device is more economical than the rental.
Procedure Codes
E0603, E0604

In lieu of an electric breast pump, purchase of a manual breast pump is eligible for reimbursement when one of the above criteria is met.

Procedure Codes

Accessories are considered eligible for reimbursement when the purchased breast pump is eligible for reimbursement.

Procedure Codes
A4281, A4282, A4283, A4284, A4285, A4286

When the above criteria are met, breast pumps meet the definition of DME and payment may be made for a breast pump according to the member's DME benefits.
Breast pumps and accessories not qualifying for coverage in accordance with the above criteria do not meet the definition of durable medical equipment (DME). Therefore, they are not covered under the member's contract.

The criteria above regarding an electric breast pump, a manual breast pump and accessories does not apply to those groups that follow the Women’s Health Federal Mandate effective August 1, 2012.

Procedure Codes
A4281, A4282, A4283, A4284, A4285, A4286, E0602, E0603, E0604

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Place of Service: Inpatient/Outpatient

The use of an electric breast pump is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements

A network provider can bill the member for the non-covered service.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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