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medical necessity
April 13th, 2016

Medical Necessity According to Insurance

Medical necessity is a term that refers to a decision made by your insurance company that your treatment, procedure, product or test is necessary for your health or to treat a current medical issue. Most insurance plans will not pay for items they do not deem to be medically necessary- but how could all this possibly pertain to breastfeeding?

Breast feeding supplies and equipment are included in the Affordable Care Act under women’s preventative services (because breast pumps and supplies allow women to provide their child with excellent nutrition (breast milk), and should not be subject to medical necessity. Some policies; however, are not compliant- for a variety of reasons. Your policy may be grandfathered, the benefit may be excluded, or our plan might be ‘self funded’. If this is the case- your pump or supplies may be subject to medical necessity. This means something must be problematic for this benefit to be covered- either you must have inverted nipples, the baby might have tongue tie, cleft palate, etc (to be determined by your physician).

Medical necessity also affects what accessories you’re covered for. Most insurance companies (even compliant policy types), will only cover what is necessary to express the milk- the motor itself, tubing, breast shields, and typically two milk storage container (such as with the Medela PNSA Starter Set, exclusively available through health insurance.

Most mommies need addition items- imagine having to pump, then go to a sink either in the workplace or at a relatives house, and transfer your milk from the two containers into a storage bag and this really is not convenient. You may also need a battery, as most of these pumps plug into the wall but you may not have convenient access to an outlet where you are pumping. Upgraded packages come with these items (such as the Medela Freestyle), but also have an upgrade fee. This upgrade fee stems from the items not billable, and therefore not covered by your insurance company (such as the cooler tote and battery), but the pump itself is still hundreds of dollars less than it would be without your insurance coverage.

For more information on what supplies are covered through your insurance, contact the skilled Breast Pump Team at Aeroflow Healthcare at 844-867-9890. To see what your policy covers, complete the simple three-step Qualify Through Insurance form, and a representative will contact you within 3-5 business days with your options.

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