5101:3-10-25 Lactation pumps.

(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 a physician or advanced practice nurse (APN) involved in the consumer’s care.

(B) Prior authorization is not needed for any issuance of a lactation pump for purchase.

(C) Hospital grade (HG) rental lactation pumps do not require a prior authorization for the first ninety days of the rental period. The rental may be extended beyond the initial ninety day program rental period with receipt of a prior authorization. Total rental period for a HG lactation pump will not exceed one hundred eighty days to include the initial rental period.

(D) Reimbursement for lactation pump purchase of either an electric or manual lactation pump will include in the equipment cost at a minimum, a one year manufacturer’s warranty that covers product malfunction, repair or replacement in the purchase price.

(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 and most recent revision of the PA form (JFS 03142, rev. 02/2003), including pertinent information such as quantity requested, manufacturer, style or model number and size.

(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) Documentation to establish medical necessity of the requested item for the extension of the initial HG rental period.

(4) Written prescription that is signed by a physician or APN involved in the consumer’s care verifying the need for the continued use of a HG lactation pump. This prescription cannot be over thirty days old from the time the PA is requested.

(F) In order for a breast pump to be eligible for program reimbursement, the following criteria must also be met:

(1) The HG 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 mm Hg and two hundred fifty mm Hg and a mechanism to prevent suction beyond two hundred fifty mm Hg

(2) The HG pump must have an adjustable pumping speed capable of reaching fifty- two cycles per minute.

(3) The HG pump must be cleaned and serviced as needed between rentals.

(G) Rental payments for HG lactation pumps are considered “all inclusive,” 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) HG 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) “All inclusive” HG accessories are the responsibility of the DME vendor to provide during the consumers 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 an HG 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 HG 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 HG pump must keep in the consumers record documentation to demonstrate that the HG pump was actively being utilized by the consumer during the time frame for which compensation was sought. The type of documentation that meets this requirement is left to the discretion of the DME vendor. This documentation must be available for review at the request of ODJFS.

(L) Inpatient lactation services 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 ) payment.

Effective: 09/01/2005

R.C. 119.032 review dates: 09/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02