OAR 410-122-0250
Breast Pumps

(1)

Indications and limitations of coverage and medical appropriateness:

(a)

The Division of Medical Assistance Programs (Division) may cover electric breast pumps for any of the following conditions:

(A)

Medical appropriateness for infant:

(i)

Pre-term;

(ii)

Term and hospitalized beyond five days;

(iii)

Separated from mother for an undetermined length of time;

(iv)

Cleft palate or cleft lip;

(v)

Cranial-facial abnormalities;

(vi)

Inability to suck adequately;

(vii)

Re-hospitalized for longer than two days;

(viii)

Failure to thrive;

(B)

Medical appropriateness for mother:

(i)

Breast abscess;

(ii)

Mastitis;

(iii)

Hospitalized due to illness or surgery (for short-term use to maintain lactation);

(iv)

Short-term treatment with medications that may be transmitted to the infant;

(v)

A hand pump or manual expression has been tried for one week without success in mothers with established milk supply;

(b)

Documentation that transition to breast feeding started as soon as the infant was stable enough to begin breast feeding;

(c)

Use E1399 for an electric breast pump starter kit for single or double pumping;

(d)

An electric breast pump starter kit will be reimbursed separately from the breast pump rental;

(e)

Electric breast pump rental cannot exceed 60 days,

(f)

An electric breast pump may only be purchased when cost effective for one of the following conditions:

(i)

Cleft palate or cleft lip;

(ii)

Cranial-facial abnormalities;

(iii)

Inability to suck adequately;

(iv)

Infant is separated from mother for an undetermined length of time;

(g)

Electric breast pump rental charges apply to the purchase price;

(h)

The following services are not covered:

(i)

Accessories;

(ii)

An electric breast pump for the comfort and convenience of the mother;

(iii)

Supplemental Nutrition System (SNS);

(iv)

Heavy duty, hospital grade breast pumps;

(v)

Replacement parts.

(2)

Documentation requirements:

(a)

For services that require prior authorization (PA): Submit documentation for review which supports conditions of coverage as specified in this rule are met;

(b)

For services that do not require PA: Medical records which support conditions of coverage as specified in this rule are met must be on file with the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and made available to the Division on request.

(3)

Procedure Codes:

(a)

E0602 — Breast pump, manual, any type — the Division will purchase;

(b)

E0603 — Breast pump, electric (AC and/or DC), any type:

(A)

The Division will purchase or rent on a monthly basis;

(B)

PA required; .

(c)

E1399 — Electric breast pump starter kit;

(A)

The Division will purchase;

(B)

PA required.

Source: Rule 410-122-0250 — Breast Pumps, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-122-0250.

California:	Codes
Colorado:	C.R.S.
Nevada:	NRS
New York:	Laws
Oregon:	OAR, ORS
Texas:	Statutes
World:	Rome Statute, International Dictionary

OAR 410-122-0250 Breast Pumps

(1)

(a)

(A)

(i)

(ii)

(iii)

(iv)

(v)

(vi)

(vii)

(viii)

(B)

(i)

(ii)

(iii)

(iv)

(v)

(b)

(c)

(d)

(e)

(f)

(i)

(ii)

(iii)

(iv)

(g)

(h)

(i)

(ii)

(iii)

(iv)

(v)

(2)

(a)

(b)

(3)

(a)

(b)

(A)

(B)

(c)

(A)

(B)

OAR 410-122-0250
Breast Pumps