What counts as "medically necessary?"

Medical necessity is a term that refers to a decision made by your insurance company that your treatment, procedure, product or test is necessary for your health or to treat a current medical issue.

Breastfeeding supplies and equipment are included in the Affordable Care Act under women’s preventative services because breast pumps and supplies allow women to provide their child with excellent nutrition (breast milk).

Exceptions

Some policies, however, are not compliant for a variety of reasons. Your policy may be grandfathered, the benefit may be excluded, or our plan might be ‘self funded’. If this is the case, your pump or supplies may be subject to medical necessity. This means something must be problematic for this benefit to be covered — either you must have inverted nipples, the baby might have tongue tie, cleft palate, etc. (to be determined by your physician).

Breastfeeding accessories & insurance coverage

Medical necessity also affects what accessories you’re covered for. Most insurance companies (even compliant policy types), will only cover what is necessary to express breast milk. This generally includes the pump motor itself, tubing, breast shields, and typically two milk storage containers (such as with the Medela PNSA Starter Set, exclusively available through health insurance.

Most mommies need additional items for a successful pumping experience. Imagine having to pump, then go to a sink either in the workplace or at a relatives house, and transfer your milk from the two containers into a storage bag! This is not convenient, to say the least.

Consider upgrading your covered pump for extra supplies

When pumping away from home, you may also need a battery, as most pumps plug into the wall, but you may not have convenient access to an outlet where you are pumping. Upgraded packages come with these items (such as the Medela Freestyle), but also have an upgrade fee. This upgrade fee stems from the items not billable, and therefore not covered by your insurance company (such as the cooler tote and battery), but the pump itself is still hundreds of dollars less than it would be without your insurance coverage.

For more information on what supplies are covered through your insurance, contact the skilled Breastpump Team at Aeroflow Breastpumps at 844-867-9890. To see what your policy covers, complete the simple three-step Qualify Through Insurance form, and a representative will contact you within 3-5 business days with your options.


Information provided in blogs should not be used as a substitute for medical care or consultation.