MedicaidPrior AuthMedium impact
MAB2025122202
Pennsylvania Medicaid (DHS)·PA · OB-GYN, Pediatrics, Family Medicine·Provider Bulletin
Effective date
Dec 22, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid now requires prior authorization for hospital-grade breast pump rentals (HCPCS E0604) extending beyond 6 months. Providers must submit specific documentation including infant growth records and justification for why standard pumps are inadequate before continuing rental coverage.
Action Required
Immediately: Update billing system to flag HCPCS E0604 (hospital-grade breast pumps) for prior authorization after 6 months of rental. Train billing staff to collect required documentation: infant gestational age, birth weight/length, growth records, beneficiary medications, and justification why personal pumps don't meet needs. Claims submitted without prior auth after 6 months will be denied.