W-2 Agencies Coverage of an additional type of breast pump and revised clinical guidelines Wisconsin Medicaid has revised the clinical and prior authorization documentation requirements for breast pumps.
Documentation indicates there is adequate milk production.
Documentation shows there is a long-term need and planned use of the breast pump to obtain a milk supply for the infant. The recipient is capable of being trained to use the breast pump as indicated by the physician or provider. Providers are required to obtain and maintain on file the doctor's orders documenting the clinical requirements of the individual's need for a breast pump. The suction level and time interval mimic natural infant suckling. This suction and rhythm standard is the minimum requirement for W6819.