Insurance Reimbursement of Breast Pumps – Sample Letter

March 20, 2012. Posted in: Mother-2-Mother.com,Pumping issues

Reprinted from Mother-2-Mother.com (2000-2006), with permission from the author, Paula Y.

UPDATE: Federal law now includes breast pumps and other supplies that directly assist with lactation as medical care expenses.

Here is a letter written by a fellow breastfeeding mom (Thank you for sharing this Kerry!).  Her pediatrician gladly signed it and said it was well-written. We both expect it to do the trick. If someone else needs such a letter, feel free to use this one as a start:

To Whom It May Concern:

The American Academy of Pediatrics supports the medical benefits of breastfeeding in its position statement, which notes that, “Breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice [1].” Physical separation of mother and baby presents a medical need for expressed breastmilk.

[MOM’s NAME] and her [SON/DAUGHTER] are separated for approximately 10 hours a day 5 days a week and occasionally for extended periods of approximately 2 weeks. Breastmilk accounts for greater than 50% of her [SON/DAUGHTER]’s caloric intake and there is no comparable substitute for the immunological properties her breastmilk provides. During these periods of separation, a breastpump is the only means for providing breastmilk to her [SON/DAUGHTER]. Therefore, [MOM’s NAME] requires a quality double-electric breastpump (such as the Hygeia EnJoye), any necessary replacement parts, and/or a quality manual pump.

In addition to providing optimal nourishment and antibodies for [MOM’s NAME]’s [SON/DAUGHTER] during periods of separation, using a breastpump addresses the following medical conditions for [MOM’s NAME]: (1) prevents engorgement of the breasts (ICD-9 code 676.24); (2) reduces the risk of plugged milk ducts and treats plugged milk ducts should they occur (ICD-9 code 675.24); (3) reduces the risk of mastitis (ICD-9 code 675.14 or 675.24); (4) maintains milk supply/prevents suppressed lactation (ICD-9 code 676.54).

Sincerely,

[DOC'S NAME]

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[1] American Academy of Pediatrics Section on Breastfeeding. “Breastfeeding and the use of human milk.” Pediatrics, vol. 129, no. 3 [March 1, 2012]:pp. e827-e841.

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Bdaltonibclc March 21, 2012 at 1:00 pm

Did this mother get payment for her pump?

Anapd March 29, 2012 at 12:04 pm

I just emailed my insurance company regarding this.  It seems they only cover if it’s medically required, which doesn’t align with the info above.  Can someone decipher this?

[Insurance company] only covers a breast pump as medically necessary when either of the following criteria is met:

The infant and mother are separated due to hospitalization, and direct breastfeeding is not possible.
The infant has a medical condition or congenital anomaly that prevents effective breastfeeding.

Mwaterbury April 15, 2012 at 5:28 pm

Your company will only cover a pump if u need to pump because there is some type of illness that makes it so the baby can’t directly latch on to the breast.

Wendy October 8, 2012 at 9:05 pm

What the insurance company will cover and what you can deduct as a medical expense (in excess of the AGI floor) on your tax return (or what you can use your flex spending account to pay for) are really two different things. My insurance company also will not cover breast pumps that are not considered “medically necessary”, but because of the change to the federal law, I can include the breast pump in my medical expenses for the year, of which the amount over my AGI floor is deductible (note that no tax advice is intended here….) In my opinion, the intent of the letter above is meant to convince the insurance company that the pump should be considered medically necessary (the author is providing diagnosis codes as support) and should thus be covered.

I am not sure what the purpose of the links to the IRS publications is, other than to suggest that since they are accepted as medical expenses by the IRS they should also be covered by insurance. I certainly agree with that thought though!

B3autiful3y3z March 29, 2012 at 10:19 pm

Insurance companies may only cover it if it is medically necessary but if you have a Flexible Spending Account they will pay for it

Jessica M Norman May 1, 2012 at 4:43 am

Not sure if this reader already knew this but I do notice a lot of people that say flexible spending accounts pay for this…. An some of those people dont realize that in reality they are still paying for it. Just through their paycheck with a slight tax advantage. It has surprised me how many people think if their flex pays it they are getting it free…

Jill May 23, 2012 at 12:45 pm

Our insurance co covered any pump that I wanted as long as it was purchased from one of their approved medical supply companies (no medical need necessary).  So I chose the best – a hospital grade Medela just like I used in the hospital.  What they failed to mention was that after the end of the yr, I’d have to pay my deductible & monthly copays for another yr.  Ended up paying about $350 out of pocket for it but it is valued at over $1200 (or over $5000 if you ask the medical supply co that I had to use). 

My biggest advice if you go this route is NOT to get one from Apria.  They messed this up royally which is why I ended up paying so much out of pocket.  They actually owe me about $150 but I’ll probably never see a penny of it.

Ladybug September 19, 2012 at 4:26 pm

When my baby is born, she will be under one health care plan (Blue Shield of California) while I will be on another (Anthem Blue Cross of California) due to COBRA.  Who do I ask if they will reimburse, my insurance or the baby’s insurance?  

MTH81 April 29, 2013 at 4:46 pm

Even with the new requirements under ACHA aka Obamacare, BCBS FL would not cover electric breastpump, and stated that it is considered a convenience item unless mother and baby is separated (extended hospitalization), medical conditions prevention latching, etc. BCBS FL’s representative stated that they meet all guidelines of ACHA by providing a manual pump to lactating mothers.