A4284, Breast shield and splash protector for use with breast pump, replacement
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- (Inferred) Documentation of newborn hospitalization/detention dates and clinical record showing the newborn remained hospitalized after the mother's discharge to support rental of a reusable pump while infant detained.
- (Inferred) Clinical documentation of congenital disorder(s) that interfere with feeding (diagnosis, relevant clinical notes, and/or applicable ICD‑10 code such as Q35.x–Q38.x) to support continued pump use up to 12 months of age.
- (Inferred) For purchase under DHHS-applicable plans: documentation of pregnancy or postpartum encounter (e.g., encounter codes Z34.x, Z39.x) or documentation that the member plans to breastfeed (including adoptive mothers) and any prescriptive order or DME order for the pump.
- (Inferred) Physician order/prescription or DME order authorizing rental or purchase of a breast pump (type and duration), including specification if hospital-grade pump rental is required while infant is detained in hospital.
Key Coverage Criteria
- Rental of a reusable breast pump is medically necessary for the period of time that a newborn is detained in the hospital after the mother is discharged (rental not medically necessary once the newborn is discharged).
- Rental of a reusable breast pump is medically necessary for infants with congenital disorders that interfere with feeding, for up to 12 months of age.
- Under new health plans and non-grandfathered plans subject to DHHS requirements (coverage beginning the first plan year on or after August 1, 2012): purchase of a manual breast pump or standard electric breast pump is medically necessary during pregnancy or at any time following delivery for breastfeeding.
- Under DHHS-applicable plans: purchase of a manual or standard electric breast pump is medically necessary for women who plan to breastfeed an adopted infant (when the above criteria are met).
- Rental of a heavy-duty electrical (hospital-grade) breast pump is medically necessary for the period of time that a newborn is detained in the hospital.
- For women using a breast pump from a prior pregnancy, a new set of breast pump supplies is medically necessary with each subsequent pregnancy for initiation or continuation of breastfeeding during pregnancy or following delivery.
2 Active Policies
AETNA-CPB-0421, Breast Pumps
CIGNA-A004, Preventive Care Services
Related Codes
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