Medical Necessities

From boosting a child’s immune system and ensuring they maintain a healthy weight to minimizing postpartum bleeding and reducing the risk of certain types of cancers in mothers, breastfeeding bears near-endless benefits for babies and their moms. Breast milk accounts for more than 50 percent of an infant’s caloric intake, and breast pumps play a crucial role in providing your baby breast milk when you are unable to nurse.

Using a breast pump also has several other benefits for the nursing mother including:

  • The prevention of breast engorgement
  • Reduced risk of plugged milk ducts and their treatment, should they occur
  • Reduced risk of mastitis
  • The maintenance of milk supply and prevention of suppressed lactation

When it comes to determining whether or not mothers and their babies are eligible for an insurance-covered breast pump, every health insurance provider has a different set of rules. The most common reasons for a pump include when a mother resumes work or school, an infant is in the NICU, or a breast pump is medically necessary. A breast pump can be medically necessary under the following circumstances:

  • A baby lacks the ability to initiate breastfeeding because of a medical condition like prematurity or oral defect.
  • Temporary weaning due to separation, a mother’s medication or the need for a contraindicated diagnostic test.
  • Inadequate supply of milk
  • Breast infection
  • Engorgement
  • Ineffective latch

Thanks to the Affordable Care Act, breastfeeding insurance coverage is becoming more comprehensive. As a result, the tools and support necessary for child nourishment are now readily accessible. Below we highlight recent breastfeeding coverage changes that might have affected your healthcare plan and how to ensure you get all you are entitled to.


How Breastfeeding Insurance Coverage has Changed Under the Affordable Care Act

As per the Affordable Care Act, private carriers have to offer breastfeeding insurance coverage for every new mother without cost sharing. Apart from providing breastfeeding education and support every time you deliver, your insurance plan has to provide a breast pump without requiring a co-pay.


What Your Insurance Provider Covers

As mandated by the Affordable Care Act, insurance plans have to provide breast pumps as well as lactation counseling. Offers will, however, vary based on your specific plan. Consulting with your insurance provider is your best option when it comes to finding out what your plan offers.



Most insurance providers consider the rental of reusable breast pumps medically necessary in one of the following circumstances:

  • During the time a newborn is detained at the hospital after its mother has been discharged.
  • When an infant has a congenital disorder, one that interferes with breastfeeding.


Insurance providers rarely cover breast pump purchases that aren’t subject to DHHS (Department of Health and Human Services) requirements for breast pump coverage. Since commercially available non-reusable electric or manual breast pumps are frequently used in the absence of injury or illness, most insurance providers consider them outside the standard contractual definition of DME (durable medical equipment). Some breast pump-related items are almost never covered including:

  • Baby weighing scales
  • Batteries, battery packs and battery-powered adaptors
  • Bottles not specific to the operation of breast pumps including their nipples and caps
  • Breast milk storage bags, labels, labeling lids, ice-packs and similar products
  • Breast pump cleaning supplies such as soap, wipes, sprays and steam cleaning bags
  • Products that soothe breasts or nipples such as creams and ointments
  • Electrical power adapters
  • Nursing bras, bra pads, nipple shields, breast shells and similar products
  • Garments or products that enable hands-free pump operation
  • Travel or carrying accessories



Depending on your insurance provider, some policies apply to the new health plans currently subject to DHHS requirements for the coverage of breast pumps.

  • The purchase of a standard electric or manual breast pump for breastfeeding is considered medically necessary during pregnancy or any time after delivery and for mothers who have met the criteria and plan to breastfeed adopted infants.
  • The rental of a hospital grade (heavy duty) breast pump is considered medically necessary while a newborn is being detained at the hospital.
  • For the continuation or initiation of breastfeeding while pregnant or after delivery, a new set of related supplies is deemed medically necessary with every subsequent pregnancy for those using breast pumps from prior pregnancies.
  • For breastfeeding while pregnant or after delivery, replacing a manual breast pump is deemed medically necessary for every subsequent pregnancy.
  • For breastfeeding while pregnant or after giving birth, for members who haven’t received this type of breast pump within the past three years, or if the first unit is broken and out of warranty, replacing a standard electrical breast pump is deemed medically necessary.
  • The purchase of hospital grade (heavy duty electrical) breast pumps is not considered medically necessary. However, chances are you can rent a hospital-grade breast pump, especially since most insurance companies cover them. Pre-authorization might be a requirement for this type of breast pump. As such, you need to ask your provider if you need proof of medical necessity or a prescription.

If your provider does not offer the services or products you want, fear not. Approximately 60 percent of healthcare plans allow subscribers to pay the difference and upgrade from basic options to whatever pump they choose. When getting your breast pump, make sure you go through a distributor who accepts your insurance.


Ameda makes things simple. All you need to get started is your due date, insurance card, your policy number and your physician’s information. Fill out our online form to find out if you are eligible to receive one of Ameda’s insurance-approved breast pumps.