Milk (Banked Donor)
Banked donor milk may be covered as a medically necessary food when the mother’s milk is contraindicated, unavailable due to a medical or psychological condition or insufficient in quantity or quality to meet the infant’s dietary needs. It may also be covered due to the birth mother’s physical absence (for example, adoption, maternal death or deployment of the active duty service member mother).
Coverage includes up to 35 ounces per day. The initial prescription is valid for 30 days and must include the quantity and frequency. If additional milk remains medically necessary, the prescription must be renewed every 30 days thereafter. Banked donor milk must be procured through a milk bank accredited through the Human Milk Banking Association of North America (HMBANA).
To be considered for coverage, the infant must have one or more of the following conditions:
- born with a birth weight less than 1,500g, gastrointestinal anomaly, metabolic/digestive disorder, or recovery from intestinal surgery where digestive needs require additional support,
- diagnosed with failure-to-thrive and other feeding options have been exhausted or are contraindicated,
- formula intolerance with either documented feeding difficulty or weight loss and other feeding options have been exhausted or are contraindicated,
- congenital heart disease,
- pre- or post-organ transplant, or
- other serious health conditions when the use of banked donor milk is medically necessary and will support the treatment and recover of the infant.
An approval from Health Net Federal Services, LLC is not required. However, all beneficiaries must obtain a prescription from the treating provider for claims reimbursement.
Important things to remember for reimbursement:
- The prescription provided to the beneficiary or HMBANA banked donor milk supplier must include the quantity (in ounces) and frequency.
- A new prescription is required every 30 days.
- When billing for greater than 35 ounces in a single day, you must include the date range on the claim.
- Documentation that the beneficiary meets the medical needs for coverage as indicated above is also required for proper reimbursement.
In lieu of separate clinical documentation, the treating provider can complete a Banked Donor Milk Coverage Criteria Attestation to be submitted with the claim.
When provided in an inpatient hospital setting, banked donor milk costs may be included in the inpatient stay. However, if the patient is not inpatient, copayments and cost-shares will follow durable medical equipment rates. Reimbursement is calculated as medical foods using HCPCS code T2101 per ounce, which includes processing, storage and distribution.