Summary
Effective December 22, 2025, prior authorization is required for all prescriptions for hospital grade breast pumps after six months of rental, and the updated guidelines set the criteria for continued rental. Continued rental is medically necessary when the beneficiary is unable to nurse and provide adequately for the infant and personal use of manual or electric breast pumps does not adequately meet maternal or infant needs, or when the beneficiary takes medications that can be found in breast milk and would harm the infant.
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What to do
Action · 4 steps
01Already effective December 22, 2025: Get prior authorization for E0604 (Breast Pump, Hospital Grade, electric) for all prescriptions for continued rental after six months of rental.
02Billing team: Use the PROMISe Provider Handbook prior authorization sections for hospital grade breast pumps, Section 7.1.2.5 for 837 Professional/CMS-1500 claims and Section 7.1.2.3 for 837 Institutional/UB-04 claims.
03Include the following with the authorization request: gestational age of infant(s), birth length and weight of infant(s), growth record of infant(s), medication list of beneficiary, and documentation of any other pumps used (e.g., personal use manual or electric) and why they do not meet the needs of the beneficiary or infant.
04Questions about prior authorization for managed care members go to the appropriate managed care organization.
Codes mentioned
E0604
Original notice
MAB2025122202
pa.gov · Always check the source before changing claims.