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.
410‑122‑0010
Definitions
410‑122‑0020
Orders
410‑122‑0040
Prior Authorization
410‑122‑0080
Conditions of Coverage, Limitations, and Restrictions
410‑122‑0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients)
410‑122‑0180
Healthcare Common Procedure Coding System Level II Coding
410‑122‑0182
Legend
410‑122‑0184
Repairs, Servicing, Replacement, Delivery, and Dispensing
410‑122‑0186
Payment Methodology
410‑122‑0188
DMEPOS Rebate Agreements
410‑122‑0200
Pulse Oximeter for Home Use
410‑122‑0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea
410‑122‑0203
Oxygen and Oxygen Equipment
410‑122‑0204
Nebulizer
410‑122‑0205
Respiratory Assist Devices
410‑122‑0206
Intermittent Positive Pressure Breathing
410‑122‑0207
Respiratory Supplies
410‑122‑0208
Suction Pumps
410‑122‑0209
Tracheostomy Care Supplies
410‑122‑0210
Ventilators
410‑122‑0211
Cough Stimulating Device
410‑122‑0220
Pacemaker Monitor
410‑122‑0240
Apnea Monitors for Infants
410‑122‑0250
Breast Pumps
410‑122‑0260
Home Uterine Monitoring
410‑122‑0280
Heating/Cooling Accessories
410‑122‑0300
Light Therapy
410‑122‑0320
Manual Wheelchair Base
410‑122‑0325
Power Wheelchair Base
410‑122‑0330
Power-Operated Vehicle
410‑122‑0340
Wheelchair Options/Accessories
410‑122‑0360
Canes and Crutches
410‑122‑0365
Standing and Positioning Aids
410‑122‑0375
Walkers
410‑122‑0380
Hospital Beds
410‑122‑0400
Pressure Reducing Support Surfaces
410‑122‑0420
Hospital Bed Accessories
410‑122‑0475
Therapeutic Shoes for Diabetics
410‑122‑0510
Osteogenesis Stimulator
410‑122‑0515
Neuromuscular Electrical Stimulator (NMES)
410‑122‑0520
Glucose Monitors and Diabetic Supplies
410‑122‑0525
External Insulin Infusion Pump
410‑122‑0540
Ostomy Supplies
410‑122‑0560
Urological Supplies
410‑122‑0580
Bath Supplies
410‑122‑0590
Patient Lifts
410‑122‑0600
Toilet Supplies
410‑122‑0620
Miscellaneous Supplies
410‑122‑0625
Surgical Dressing
410‑122‑0630
Incontinent Supplies
410‑122‑0640
Eye Prostheses
410‑122‑0655
External Breast Prostheses
410‑122‑0658
Gradient Compression Stockings/Sleeves
410‑122‑0660
Orthotics and Prosthetics
410‑122‑0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses
410‑122‑0678
Dynamic Adjustable Extension/Flexion Device
410‑122‑0680
Facial Prostheses
410‑122‑0700
Negative Pressure Wound Therapy Pumps
410‑122‑0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0250’s source at or​.us