Professional Documents
Culture Documents
Bollman, TLBM
Hand Expression Protocols
Pros Cons
■ More Milk Later ■ Stable moms still can’t perform
■ More Colostrum Collected ■ Non-compliance
■ More confidence ■ Staff time / Compliance
■ Better compliance ■ Poor technique
■ Unclear timing and frequency
MECHANICAL
BREAST PUMPS
Research
FDA - Definitions
■ Outcomes
– Pumping at -150mmGh suction/vacuum
■ increased milk supply and OL II
– Boosted maternal confidence in breastfeeding
– Increased nipple discomfort (similar to NSVD mothers)
– Too high pressure is not optimal
“Extremely high sucking strength (−237.7 ± 59.6 mmHg) leads to a lowered flow
rate of milk transfer.”
Zhang, et.al. (2017)
High vacuum
and nipple
pain
Infants in Pain Group exhibit Stronger
Vacuum and took less milk:
Baseline = -90mmGh
Peak = -214mmGh
Pause = -104mmGh
PROS CONS
■ Comparable to Medela PIS ■ Name recognition
■ Compatible with Medela parts
■ Endear is “Lactina” (E0604)
■ DME –can cover some Medi-Cal
Limerick Pride Multi-User Breast Pump
PROS CONS
■ Closed System ■ Expensive - Lowest price = $400
■ -250 mmHg ■ Unknown name recognition,
■ silicone flanges for comfort and ■ Not reimbursable by many
mimicking compression of baby insurance providers
■ one-size fits all flange ■ Can’t even buy from Amazon
■ minute timer shows how many ■ Only available on website
minutes pumping
■ Not rentable
■ ability to save the settings for next
use
■ positive messages to mother while
she pumps
■ COLOSTRUM COLLECTION
Limerick
■ Evaluation of Milk Production with a Multi-User, Electric Double Pump with a Soft
Flange in Mothers of Very Low Birth Weight (VLBW) (<1500 GM, ≤31 WK Gest) NICU
Infants: a Pilot Study - White, et.al. (2011)
■ Research funded by manufacture
■ “The PJs comfort® multi-user pump is a viable alternative to larger, more expensive
pumps for establishing an adequate milk supply in mothers of VLBW infants in the
NICU.”
Medela – Symphony, PIS and Sonata
Medela
Research
• FUNDS RESEARCH
• Durable Equipment
• Simple to use
Use Maintain:
-milk volumes >20ml for 3 sessions How long
-watch flow – adjust suction – switch phases with flow
NOT CORRECT
Massage Expression
• After let down, Press three waves button to
■ Pump starts in Expression
get into Expression Mode
■ Push the three waves button to get • Cycles adjustable (38-54 cycles)
into Massage
• Adjust Vacuum (suction L1-L12)
■ Set at 70 cycles (Not adjustable)
• L12 = 250mmHg
■ Facilitate Let down
• Turns off automatically at 30min
■ Adjust Vacuum (suction L1-L5)
Willow
Willow
PROS CONS
■ Can adjust Suction ■ Expensive
(Stim/Expression)
■ Warranty for 1 year
– Levesl 1-7 in Expression)
■ Very large/small breasts?
■ Single User, 1 year
■ Milk collection bags $1 each?
■ Wearable pump
– Only holds 4 oz
– Senses let down - automated
■ Flange 24 and 27 – offers
measuring size 21-30
– Bra size G-H
■ Good for multi-tasking, service
■ Willow App
■ Customer Services – Excellent
– “Willow Coaching Program”
Other Pumps
■ Ardo “Calypso”
■ Avent
■ Evenflo
■ Lansinoh
■ Naya
■ Pigeon
■ Real Bubee
MANUAL PUMPS &
LACTATION AIDS
Primo-Lacto Colostrum Collector
PROS CONS
■ Closed System for Colostrum Collection
■ Cost:
– No transfer from spoons or – $13/kit
medicine cups – includes hand expression funnel
– Dedicated tool for colostrum collector cup,
collection ■ if using an enteral slip tip syringe
– Reduces risk of contamination – has to be on tight
■ NICU babies at higher risk for – can slip off and lose milk
contamination
– Enfit syringes are secure because
– Collection easier, lose less they screw on
colostrum
– Promotes appropriate amount
expectations
– Hand expression collection cup
Primo-Lacto Colostrum Collector
■ Insert video
Hakaa
PROS CONS
■ Collects milk 1-2oz ■ Confusion “Fore/Hind Milk”
■ Uses some negative pressure ■ At risk infants
– Collects leaking milk – may not get enough
■ Moms love ”saving” the milk ■ At risk milk supply
■ Moms who hate pumping - LOVE – not enough stimulation
Laktek Flanges and Pump to Bottle
PROS CONS
■ Soft silicone flange ■ No evidence it works
– Supposed to mimic baby suckle
■ Promotes pumping
■ Pump / Feed during travel
■ Exclusive Pumping Mom ■ Still hard to hold baby and manage
– Helps to pump/feed at same paced feeding
time
– Fresh milk to baby
Laktek – Pump to Bottle
Pumpin’ Pal
Compression Bras
• MOU
• Crutches
• Walkers
• Wheelchairs
DME Closets
Benefits
Mother
Medial Team
DMEs benefit
■ The person who knows the rules of the game – can WIN!
■ If you don’t chart appropriate for medical necessity, code
appropriately on prescriptions – you may not get paid, or delays
■ Hospitals and providers contract with Health Plans
■ Health Plan payors
– will pay based on nationally recognized utilization management
guidelines for “medical necessity”
Medical Necessity & Charting
■ From the Chief Medical Officer in response to whether there are Utilization
Management guidelines for Breastfeeding Support, Supplies and Counseling:
“Lactation and breast feeding are not medical conditions (neither
covered nor noncovered).
Therefore, Apollo does not have a clinical guideline.
Formula to feed an infant is also not covered unless a medical
indication requires a special infant formula.
Breast pumps may be covered by some health plans such as Anthem.
The contact may find the Anthem policy for Medi-Cal members of
interest and helpful”
HOW CAN WE WIN
WITHOUT RECOGNITION
AND GUIDANCE FROM
HEALTH PLANS?
Laws & Policies
– Federal Law: ACA requires health plans and contracted physicians to provide
DME Pumps
1. Provide breastfeeding promotion, education and counseling services, integrated into perinatal,
postpartum and pediatric services.
2. Provide medically necessary interventions, including access to DME.
3. Implement procedures to ensure that postpartum mothers receive necessary breastfeeding
counseling and support after delivery.
4. Have appropriate procedures to refer to lactation professionals.
5. Refer to WIC
6. Offer health education (if contracted) in breastfeeding (detailed instructions in policy.)
7. Not market formula.
8. Provide lactation aids (DME.)
9. Cover enteral feeding (i.e. banked human milk, special formulas.)
The Law
TAR Requirements
FFS MMC
■ Restricted, Straight ■ County Plans
■ Presumptive Eligibility (PE) – Two Plan
– COHP
■ Can choose provider
– Single Plan
■ Provider bills the STATE directly – Geographic Plan
■ Beneficiary (patient) has to find participating ■ Bill MC plan
providers
– Physicians ■ Must stay in network
– Pharmacies ■ Must use contracted DME
– DME providers ■ Capitated payments
Managed Care & RBO, Capitation
■ Many Medi-Cal Managed Care Health Plans have set up contracts with “RBOs” with
capitated rates:
– RBO = Risk Bearing Organization
■ Independent Practice Associations (IPA)
■ Medical Groups
– Capitation: Monthly fees to the providers
■ based on “predicted utilization”
■ LINK comprehensive list of all California RBOs and Capitated Providers
The responsibility of accessing the DME may be assigned to the RBO, not the
health plan.
Managed Care: Utilization
Management
■ These are the “go-betweens”
– They set up contracts between
■ Health Plan & Physician
■ Health Plan & Physician group
■ Health plan & FQHC
■ Health plan & Independent Practice Association (IPA)
■ They advise physicians on how to access health plan benefits
Classes
■ S9442 Lactation Classes, Non‐Physician Provider, Per Session
http://uslca.org/wp-content/uploads/2013/01/Suggestions-for-Billing-Codes-for-IBCLCs.pdf
CPT – Not in Person Consultation Codes
Not all payers….Telemedicine….
Telephone
■ 98968 Telephone with Physician Extender - 21 to 30 minutes of medical discussion
■ Genevieve gthomas@mednet.ucla.edu
■ Cristina Cristina.Morales@DignityHealth.org
Citations
ABM Clinical Protocol #10: Breastfeeding the Late Preterm (34–36 6/7 Weeks of Gestation) and Early Term Infants (37–38
6/7 Weeks of Gestation), Second Revision 2016, retrieved from
https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/10-breastfeeding-the-late-pre-term-infant-protocol-
english.pdf
Becker, GE. 2015. Methods of milk expression for lactating women (Review). Cochrane Database of Systematic Reviews
Bolman, M. et.al. (2013). The Basics of Breast Massage and Hand Expression. Retrieved from https://vimeo.com/65196007
Elad, D., et.al., (2014). Biomechanics of milk extraction during breast-feeding. Proceedings of the National Academy of
Sciences, 111(14), 5230-5235. doi:10.1073/pnas.1319798111
Forster, D. A.,et.al., (2017). Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and
Antenatal Milk Expressing [DAME]): A multicentre, unblinded, randomised controlled trial. The Lancet, 389(10085), 2204-
2213. doi:10.1016/s0140-6736(17)31373-9
Lussier, et.al., Daily Breastmilk Volume in Mothers of Very Low Birth Weight Neonates: A Repeated-Measures Randomized
Trial of Hand Expression Versus Electric Breast Pump Expression, Breastfeeding Medicine, Vol. 10, Number 6, 2015, retrieved
from https://www.liebertpub.com/doi/pdf/10.1089/bfm.2015.0014
Citations
Meier, P. et.al. (2016), Which Breast Pump for Which Mother: An Evidenced-Based Approach to Individualizing Breast Pump
Technology. J Perinatol. 36(7): 493–499. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4920726/.
Mohrbacher, Nancy, To Pump More Milk, Use Hands On Pumping, Breastfeeding USA, Retrieved from
https://breastfeedingusa.org/content/article/pump-more-milk-use-hands-pumping
Morton, J. (2012). The Importance of Hands. Journal of Human Lactation, 28(3), 276-277. doi:10.1177/0890334412444930
Ohyama, M., Watabe, H., & Hayasaka, Y. (2010). Manual expression and electric breast pumping in the first 48 h after
delivery. Pediatrics International, 52(1), 39-43. doi:10.1111/j.1442-200x.2009.02910.x
Parker, L. A., et. al., (2011). Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among
mothers of very low birth weight infants: A pilot study. Journal of Perinatology, 32(3), 205-209. doi:10.1038/jp.2011.78
Uikey, P. A., Agrawal, P., & Khandale, S. (2017). Antenatal breast milk expression at term increases postnatal lactational
performance. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 6(6), 2438.
doi:10.18203/2320-1770.ijrcog20172327
Zhang, F., et.al., (2017). Effect of pumping pressure on onset of lactation after caesarean section: A randomized controlled
study. Maternal & Child Nutrition, 14(1). doi:10.1111/mcn.12486
Links
Link to Medi-Cal DME Polices
Choose “Durable Medical Equipment (DME): Bill for DME (dura bil dme)” for guidelines on billing codes. (page 21)
Choose “Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates (dura cd)” for billing code and
reimbursement rates. (Page 43-44)
DHCS – State of California Breastfeeding Promotion Policy for Medi-Cal MMCD -98-10:
http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/PL1998/MMCDPL98010.pdf
State Medi-Cal Law:
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=WIC§ionNum=14134.55.
New Medi-Cal Provider Bulletin
DME: http://files.medical.ca.gov/pubsdoco/bulletins/artfull/dme201711.asp
Pharmacy: http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/ph201711.asp