Breast Pumps

Revised: March 9, 2026

· Overview

· Eligible Providers

· TPL and Medicare

· Eligible Members

· Covered Services

· Noncovered Services

· Authorization

· Billing

Overview

Breast pumps are devices used to extract milk from the breast of a nursing birthing person for infant feeding when the birthing person cannot be present at feeding time.

Eligible Providers

The following may provide breast pumps:

· Hospitals

· Medical suppliers

· Pharmacies

TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

Breast pumps and breast pump supplies are covered for eligible Medical Assistance and MinnesotaCare members when ordered by a physician, certified nurse midwife, or nurse practitioner for any nursing birthing person experiencing separation from their infant because of work, school, illness, or any other medical reason.

Refer to Obstetric Services section of the MHCP Provider Manual for more information on reproductive health policy.

Covered Services

Codes: E0602-E0604, A4281-A4288, A9999
Manual breast pumps (E0602) and electric breast pumps (E0603) are purchase only. The purchase of an electric breast pump is limited to one per pregnancy.

Hospital-grade breast pumps (E0604) are rental only. Bill accessory kits for hospital-grade pumps with HCPCS code A9999. The rental period of hospital-grade pumps is three months. Authorization is required for additional months if a member has medical necessity for a hospital-grade pump beyond the first three months.

Breast pumps are a personal care item that cannot be shared by mothers. Breast pumps can be used for future pregnancies. MHCP members are allowed one pump per pregnancy.

Dispensing of breast pumps includes all supplies required for device functioning. MHCP covers breast pump replacement parts (A4281 to A4286, A4288) and bags for breast milk (A4287). MHCP pays for replacement parts when the original item no longer functions. Refer to the following Breast Pump Supplies table and the Medical Supply Coverage Guide (PDF) for information on quantity limits for breast pump supplies.

Breast Pump Supplies

HCPCS Code	Code Definition	Quantity Limit
A4281	Tubing for breast pump, replacement	1 unit per dispensing, up to 2 units per year
A4282	Adapter for breast pump, replacement	1 unit per dispensing, up to 2 units per year
A4283	Cap for breast pump bottle, replacement	1 unit per dispensing, up to 2 units per year
A4284	Breast shield and splash protector for use with breast pump, replacement	1 unit per dispensing, up to 2 units per year
A4285	Polycarbonate bottle for use with breast pump, replacement	1 unit per dispensing, up to 2 units per year
A4286	Lock ring for breast pump, replacement	1 unit per dispensing, up to 2 units per year
A4287	Disposable collection and storage bag for breast milk, any size, any type, each	200 per month
A4288	Valve for breast pump, replacement	1 unit per dispensing, up to 2 units per year

MHCP considers one package as one unit for replacement parts. HCPCS codes A4281 to A4286 and A4288 are not separately reimbursable within the same month of purchase of HCPCS codes E0602 and E0603.

Noncovered Services

MHCP does not cover the following:

· Baby weight scales

· Cleaning supplies for breast pumps

· Clothing or other products that permit hands-free pump operation

· Nursing bras, bra pads, breast shells, nipple shields, and other similar products

· Replacement parts when the original part of the breast pump is functional

· Travel bags and other accessories for transporting breast pumps and supplies

Refer to information under the Noncovered Services heading in the Billing the Member (Recipient) section of the MHCP Provider Manual to review the conditions required to bill the member.

Authorization

Authorization is required for the following:

· Quantities more than allowable MHCP quantity limits

· Rentals of hospital-grade pumps beyond the initial three months

Submit authorization request and documentation to the Medical Review Agent.

Authorization is not required for manual or electric pumps.

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section in the Providers Basics of the MHCP Provider Manual for general billing information.

Bill breast pumps and supplies using MN–ITS 837P Professional. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS user manual for general billing requirements and guidance when submitting claims.

· Use modifier NU for purchases.

· Use modifier RR for rentals.

· Use modifiers KH, KI, KJ, and RR as appropriate for capped rentals.

· If the birthing person is eligible, bill breast pumps and breast pump supplies using the birthing person’s MHCP member ID number. Purchases for breast pumps for the eligible birthing person may be submitted prior to or after birth.

· If the birthing person is ineligible, bill breast pumps and breast pump supplies using the infant’s MHCP member ID number. Include the infant’s name, date of birth, and gender if billing under the infant’s MHCP member ID number.

· Bill using HCPCS code A9999 for accessory kits for hospital-grade breast pumps.