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Human Donor Milk Outpatient Coverage (IB 22-35)

Date: 11/02/22

Louisiana Healthcare Connections is sharing with providers a recent coverage of human donor milk as an outpatient service for medically vulnerable infants. This coverage is effective starting January 1, 2023. 

Donor Human Milk 

Donor human milk is covered outpatient for use by medically vulnerable infants.

Eligibility Criteria 

Donor human milk is considered medically necessary when the following criteria are met: 

1. The member is less than 12 months of age with one or more of the following conditions: 

  1.     a. Post-surgical nutrition;

    b. Organ transplantation;     

    c. Renal disease;

    d. Short gut syndrome;

    e. Malabsorption syndrome;

    f. Feeding or formula intolerance;

    g. Failure to thrive;

    h. Inborn errors of metabolism;

    i. Immunologic disorders;

    j. Congenital heart disease or other congenital anomalies; or

    k. Neonatal abstinence syndrome. 

2. The member's caregiver is medically or physically unable to produce breast milk at all or in sufficient quantities, is unable to participate in breastfeeding despite optimal lactation support, or has a contraindication to breastfeeding; or the beneficiary is medically or physically unable to receive caregiver breast milk or participate in breastfeeding; and 

3. The member's caregiver has received education on donor human milk, including the risks and benefits; and 

4. A bank accredited by, and in good standing with, the Human Milk Banking Association of North America supplied the donor human milk.   

Reimbursement

Prescriptions for donor human milk must include the following:

  1. Number of prescribed calories per ounce;
  2. Total ounces prescribed per day;
  3. Total number of weeks donor human milk is required;
  4. Total allowable refills; and
  5. Reason for prescribing donor human milk, including beneficiary’s diagnoses.

Prior authorization is not required for donor human milk. Donor human milk is, however, subject to post payment medical review. 

The DME provider must submit a prescription containing all required documentation along with a hard copy claim to the department’s fiscal intermediary. Failure to provide required documentation, or if the documentation submitted fails to establish medical necessity, will result in recoupment of the payment for the donor human milk.

Providers can review Chapter 25: Hospital Services Provider manual for policy regarding coverage of donor human milk in an inpatient hospital setting. 

NOTE: Fee-for-Service policy on coverage in inpatient hospital settings is located in the Hospital Services Provider Manual.