Breast Pumps

Revised: April 23, 2025

· Overview

· Eligible Providers

· 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 or when the infant is too sick or too weak to suck.

Refer to Obstetric Services in the Minnesota Health Care Programs (MHCP) Provider Manual for more information on reproductive health policy.

Eligible Providers

The following providers are eligible to provide breast pumps:

· Hospitals

· Medical suppliers

· Pharmacies

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 a medical reason or for an infant who is too sick or weak to suck.

Covered Services

Codes: E0602-E0604, A4281-A4287, A9999
Manual breast pumps (E0602) and electric breast pumps (E0603) are purchase only. Bill with modifier NU. The purchase of an electric breast pump is limited to one per pregnancy.

Hospital-grade breast pumps (E0604) are rental only. Bill with modifier RR. 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.

MHCP covers breast pump replacement parts (A4281 to A4286) and bags for breast milk (A4287). Refer to the following 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	186 per month

HCPCS codes A4281 to A4286 are only reimbursable when the specific replacement part of the breast pump no longer functions properly. MHCP considers one package as one unit for replacement parts. HCPCS codes A4281 to A4286 are not separately reimbursable within the same month of purchase of HCPCS codes E0602 and E0603.

Noncovered Services

MHCP does not cover the following:

· 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 rentals of hospital-grade pumps beyond the initial three months and for pump supplies when the quantity limit is exceeded. 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 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.

· If the birthing person is eligible, bill breast pumps and breast pump supplies using the birthing person’s MHCP member ID number.

· 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.

· Use modifier NU for purchases of manual and electric breast pumps.

· Use modifier RR for rentals of hospital-grade breast pumps.

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