(A) Lactation pumps are covered by the medicaid program under the following conditions:
(1) The requested lactation pump is subject to the coverage and limitations for medical supplies as defined in rule 5101:3-10-02 of the Administrative Code.
(2) The requested lactation pump is prescribed by an eligible prescriber involved in the consumer's or infant's care.
(3) The lactation pump is deemed medically necessary by the ordering prescriber when one or more of the following conditions exist:
(a) The infant is unable to initiate breast feeding due to a medical condition such as prematurity, oral defect, etc.; or
(b) Temporary weaning (i.e., direct breast feeding is not possible) due to:
(i) Mother/infant separation; or
(ii) Mother is required to take a medication or undergo a diagnostic test that is contraindicated with breast feeding; or
(c) Inadequate milk supply; or
(d) Engorgement; or
(e) Breast infection.
(4) In addition to the aforementioned criteria, the lactation pump must have been authorized by a prescriber who is actively involved in managing the consumer's or infant's medical care through a comprehensive plan of care that addresses the medical need for a lactation pump.
(B) Prior authorization is not needed for the purchase of a lactation pump .Providers must keep on file a fully completed JFS 01901, "Certificate of Medical Necessity/Prescription Lactation Pumps" (CMN) (appendix A to this rule) that is signed and dated no more than thirty days prior to the first date of service. This documentation must be available for review at the request of ODJFS.
(C) Hospital grade (HG) rental lactation pumps do not require an initial prior authorization . The rental period is ninety consecutive days. The rental period may be extended beyond the initial ninety days with prior authorization. Total rental period for a lactation pump will not exceed one hundred eighty consecutive days to include the initial rental period.
(D) Reimbursement for the purchase of either an electric or a manual lactation pump will include a one- year manufacturer's warranty that covers product malfunction, repair or replacement .
(E) Prior authorization (PA) requests for extension of the initial HG lactation pump rental period must be compliant with rule 5101: 3-10-06 of the Administrative Code. The PA request must include the following documentation:
(1) A fully completed JFS 01901, "Certificate of Medical Necessity/Prescription Lactation Pumps" (CMN) (appendix A to this rule) that is signed and dated no more than thirty days prior to the first date of service.
(2) A description, including approximate age and ownership, of any similar equipment currently in possession of the recipient and the reason for the new request if similar equipment ownership is established.
(3) Any other documentation as required or requested by ODJFS for certain specific medical supplier services, as detailed in Chapter 5101:3-10 of the Administrative Code.
(F) In order for an HG lactation pump to be eligible for program reimbursement, the following criteria must also be met:
(1) The pump must utilize suction and rhythm equivalent to the equipment commonly found in hospital settings. This means it must have an adjustable suction pressure between one hundred and two hundred fifty mm Hg and a mechanism to prevent suction beyond two hundred fifty mm Hg.
(2) The pump must have an adjustable pumping speed capable of reaching fifty- two cycles per minute.
(3) The pump must be cleaned and serviced as needed between rentals.
(G) Rental payments for lactation pumps are considered "bundled," which includes but is not limited to the following components:
(1) Set up and instructions as to pump and attachment kit usage and cleaning.
(2) Maintenance and repair during rental period.
(3) Any required attachment kit, which must be new and will become the property of the consumer upon issuance.
(4) Applicable cleaning/return service charges, unless the unit is returned excessively dirty, which is defined as the unit requires extensive cleaning before it can be utilized by another consumer, in which case the durable medical equipment (DME) vendor may seek reasonable cleaning charges from the consumer.
(H) "" Bundled accessories are the responsibility of the DME provider to dispense during the consumer's initial rental period. No replacements for lost or damaged supplies and or accessories are billable to Ohio medicaid during the rental period. Any lost or damaged supplies and/or accessories are the responsibility of the consumer to replace.
(I) Any manual lactation pump that was supplied to a consumer as part of a pump attachment kit cannot be billed to the Ohio medicaid program as a separate item by a DME vendor.
(J) Any consumer that acquires a manual lactation pump as part of a vendor supplied pump attachment kit cannot purchase an additional manual lactation pump at Ohio medicaid program expense.
(K) All DME providers that submit claims to Ohio medicaid for reimbursement of a rental lactation pump must keep in the consumer's medical record documentation to demonstrate that the lactation pump was actively being utilized by the consumer during the time frame for which compensation is sought. The type of documentation that meets this requirement is left to the discretion of the DME provider. This documentation must be available for review at the request of ODJFS.
(L) Inpatient lactation services or those provided to a resident of a long term care facility (LTCF) or an intermediate-care facility for the mentally retarded and/or DME equipment are not covered under this rule and cannot be billed separately. These services are considered a component of the diagnostic related group (DRG ) or facility per diem payment.
(M) Lactation pumps are reimbursed at the lesser of the department's fee schedule contained in appendix DD to rule 5101:3-1-60 of the Administrative Code or the provider's usual and customary charge.
R.C. 119.032 review dates: 01/03/2011 and 04/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 9/1/05