| Coverage Policy Manual | |
| Policy #: | 2011019 |
| Category: | PPACA Preventive |
| Initiated: | September 2010 |
| Last Review: | June 2023 |
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| PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: BREASTFEEDING COUNSELING | |
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| Description: |
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010. The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention. Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider. If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
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Policy/ Coverage: |
Effective April 2024
Counseling for breastfeeding is covered for members of “non-grandfathered” plans during pregnancy and after birth without cost-sharing (i.e., deductible, co-insurance, or co-pay). This benefit is limited to 5 sessions per pregnancy.
The appropriate ICD-10 code to report this service is Z39.1.
The cost of a manual breastfeeding pump is covered once per pregnancy for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay. (HRSA Recommendation)
Purchase of a breast pump should be reported using HCPCS code E0602 (manual) or E0603 (electric). Replacement supply codes include A4281, A4282, A4283, A4284, A4285, A4286, A4287.
The codes used to report this service are 99401-99404. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required
Effective June 2022
Counseling for breastfeeding is covered for members of “non-grandfathered” plans during pregnancy and after birth without cost-sharing (i.e., deductible, co-insurance, or co-pay). This benefit is limited to 5 sessions per pregnancy.
The appropriate ICD-10 code to report this service is Z39.1.
The cost of a manual breastfeeding pump is covered once per pregnancy for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay. (HRSA Recommendation)
Purchase of a breast pump should be reported using HCPCS code E0602. Replacement supply codes include A4281, A4282, A4283, A4284, A4285, A4286.
The codes used to report this service are 99401-99404. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required
Effective prior to June 2022
Counseling for breastfeeding is covered for members of “non-grandfathered” plans once per pregnancy, without cost-sharing (i.e., deductible, co-insurance, or co-pay):
The appropriate ICD-10 code to report this service is Z39.1.
The cost of a manual breast feeding pump is covered once per pregnancy for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay. (HRSA Recommendation) (EFFECTIVE 8/01/2012)
Purchase of a breast pump should be reported using HCPCS code E0602. Replacement supply codes include A4281, A4282, A4283, A4284, A4285, A4286.
The codes used to report this service are 99401-99404. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required.
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| Rationale: |
The U.S. Preventive Services Task Force (USPSTF) recommends interventions during pregnancy and after birth to promote and support breastfeeding (Grade B recommendation).
There is convincing evidence that breastfeeding provides substantial health benefits for children and adequate evidence that breastfeeding provides moderate health benefits for women.
Adequate evidence indicates that interventions to promote and support breastfeeding increase the rates of initiation, duration, and exclusivity of breastfeeding.
No published studies focus on the potential direct harms from interventions to promote and support breastfeeding. The review did not include a search for potential harms of breastfeeding itself. The USPSTF has bounded the potential harms of interventions to promote and support breastfeeding as no greater than small.
The USPSTF concludes that there is moderate certainty that interventions to promote and support breastfeeding have a moderate net benefit.
The USPSTF recommendations include the following information:
This recommendation applies to pregnant women, new mothers, and young children. In rare circumstances involving health issues in mothers or infants, such as HIV infection or galactosemia, breastfeeding may be contraindicated and interventions to promote breastfeeding may not be appropriate. Interventions to promote and support breastfeeding may also involve a woman's partner, other family members, and friends.
The current literature does not allow assessment of the individual aspects of multicomponent interventions or comparative effectiveness assessments of single-component interventions. The promotion and support of breastfeeding may be accomplished through interventions over the course of pregnancy; around the time of delivery; and after birth, while breastfeeding is under way. Interventions may include multiple strategies, such as formal breastfeeding education for mothers and families, direct support of mothers during breastfeeding observations, and the training of health professional staff about breastfeeding and techniques for breastfeeding support. Evidence suggests that interventions that include both prenatal and postnatal components may be the most effective at increasing breastfeeding duration. Many successful programs include peer support, prenatal breastfeeding education, or both.
2022 Update
In 2016, the 2008 USPSTF recommendation on primary care interventions to promote and support breastfeeding was updated (USPSTF, 2016). The scope of the review and type of interventions recommended did not change. The grade of the recommendation remains a B. The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding.
The current HRSA guideline for breast feeding services and supplies states: “WPSI recommends comprehensive lactation support services (including counseling, education, and breastfeeding equipment and supplies) during the antenatal, perinatal, and postpartum periods to ensure the successful initiation and maintenance of breastfeeding” (HRSA, 2022). WPSI indicates that clinical trials of interventions including at least 5 in-person visits across antenatal, perinatal, and postpartum periods to promote and support breastfeeding showed benefit (WPSI, 2022).
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| CPT/HCPCS: | |
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| References: |
Health Resources and Services Administration (HRSA).(2022) Women’s Preventive Services Guidelines. Accessed 5/27/2022. https://www.hrsa.gov/womens-guidelines/index.html PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act Primary Care Interventions to Promote Breastfeeding, Topic Page. October 2008. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrfd.htm U.S. Preventive Services Task Force (USPSTF).(2016) 2016. Final Recommendation Statement. Breastfeeding: Primary Care Interventions. Accessed 5/27/2022. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breastfeeding-primary-care-interventions Women’s Preventive Services Initiative (WPSI).(2022) Breastfeeding Services and Supplies. Accessed 5/27/2022. https://www.womenspreventivehealth.org/recommendations/breastfeeding-services-and-supplies/ |
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Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association. |
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