Breast Pump DME/Insurance Letter

Date: [Full date]

From: [Clinic/practice name], [Address], Phone: [Phone], Fax: [Fax], Clinician: [Clinician name, credentials, specialty]

To: [Insurer or DME supplier name], [Department], [Fax/address] (Include only if recipient is known; otherwise omit entire "To" block)

RE: [Patient full name]; DOB: [DOB]; Request for breast pump DME and supplies; [Member ID / PA Ref #] (Include member ID/PA # only if available. Include infant name and DOB only if infant clinical status is part of the justification.)

Purpose Statement

[Statement requesting coverage/authorization for breast pump and/or supplies, specifying whether for initial pump / upgrade to hospital-grade / rental extension / replacement / additional supplies, with high-level reason: maternal-infant separation / prematurity-NICU / infant unable to latch / low milk supply despite adequate frequency / maternal medical complication / return to work or school]

Clinical Context Summary

(Include only information directly supporting the pump request; omit unrelated history. Attribute sources as needed.)

Lactation status: [Current status: lactating / initiating / exclusive pumping / combination feeding], [postpartum timing], [patient feeding goal if relevant]

Maternal factors: [Recovery considerations limiting direct breastfeeding; conditions affecting lactogenesis or supply; nipple/areolar trauma requiring expressed milk plan] (Include only if directly impacting pumping need; otherwise omit)

Infant factors: [Prematurity/gestational age; NICU status and expected duration; conditions interfering with direct breastfeeding; current feeding route] (Include only if request depends on infant status; otherwise omit)

Separation logistics: [Expected separation schedule; workplace/school constraints affecting pump type or portability needs] (Include only when separation drives the request; otherwise omit)

Diagnoses/Indications

• [Objective indication with ICD-10 code if available]
• [Additional indication with ICD-10 code if available]
• [Additional indication with ICD-10 code if available]

Requested Equipment and Supplies

The following equipment and supplies are requested to meet the stated clinical needs:

Item	Type	HCPCS Code	Quantity / Refill Cadence	Duration of Need
[Breast pump with functional requirements: hospital-grade / double electric / closed system / portable]	[Purchase / Rental]	[E0603 / E0604 / pending]	[Quantity or rental period]	[Expected duration]
[Pump kit and replacement parts: flanges, tubing, valves, membranes, bottles]	[Purchase]	[A4281–A4286 / pending]	[Initial kit + replacement cadence]	[Duration]
[Additional supplies or accessories as needed]	[Purchase / Rental]	[HCPCS / pending]	[Quantity/cadence]	[Duration]

Medical Necessity Rationale

Clinical goal: [Establish/maintain milk supply; provide human milk while infant cannot latch; prevent supply loss during separation; support medically indicated expressed feeding plan]

Why the requested pump type is necessary: [Link pump functionality to clinical scenario]

Consequences without it: [Clinical and practical risks as supported by chart documentation or attributed sources]

Why alternatives are insufficient: [Limitations of manual/single-electric pumps; prior pump trial failure; nonfunctioning device] (Include only when relevant)

Milk Expression Plan

(Include only if it strengthens medical necessity; otherwise omit entire section)

• [Target pumping frequency and schedule]
• [Lactation support involvement: IBCLC / hospital lactation service with consult dates]
• [Reassessment plan and follow-up timeline]

Attachments

(List only documents attached or available upon request; omit section if none)

• [Lactation consult note]
• [NICU or discharge summary excerpt]
• [Growth/feeding plan]
• [Prior pump trial documentation]

Signature Block

Signature: _______________________________

Printed name and credentials: [Name, credentials]

NPI: [NPI]

Date signed: [Date]

Direct contact: Phone: [Phone] | Fax: [Fax]

[Optional attestation: "I certify the above information is accurate to the best of my knowledge and based on the medical record and/or patient report as specified."] (Include only if required by payer or institutional policy)