Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 17 - MEDICAL SUPPLIERS › Section 317:30-5-211.29 - Donor human breast milk

Current through Vol. 41, No. 20, July 1, 2024
(a)
Donor
				  human breast milk.
Donor human breast milk is pasteurized donor human
				  milk which has been donated to a Human Milk Banking Association of North
				  America (HMBANA) milk bank. Upon donation, it is screened, pooled, and tested
				  so that it can be dispensed. All donor mothers require screening and approval
				  by a HMBANA milk bank, and additionally, all donor milk is logged, pasteurized,
				  and monitored.
(b)
Provider
				  qualifications.
Donor human breast milk must be obtained from a milk
				  bank accredited by, and in good standing with, the HMBANA and be contracted
				  with the Oklahoma Health Care Authority (OHCA) as a Durable Medical Equipment
				  (DME) provider.
(c)
Medical
				  necessity criteria.
To qualify to receive donor human breast milk the
				  infant must meet medically necessary criteria, which can include but not
				  limited to the following conditions:
(1)
				  Other feeding options have been exhausted or are contraindicated; and
(2) Baby's biological mother's
				  milk is contraindicated, unavailable due to medical or psychosocial condition,
				  or mother's milk is available but is insufficient in quantity or quality to
				  meet the infant's dietary needs, as reflected in medical records or by a
				  physician (MD or DO), physician's assistant, or advanced practice nurse;
				  and
(3) Donor human breast milk
				  must be procured through a HMBANA entity and delivered through a contracted
				  provider, facility, or the supplier (HMBANA-accredited milk bank); and
(A) Requests for coverage over thirty-five
				  (35) ounces per day, per infant, shall require review and approval by an OHCA
				  Medical Director; and
(B) Coverage
				  shall be extended for as long as medically necessary, but not to exceed an
				  infant's twelve (12) months of age; and
(C) A new prior authorization will be
				  required every ninety (90) days.
(4) The infant has one (1) or more of the
				  following conditions:
(A) Infant born at Very
				  Low Birth Weight (VLBW) (less than 1,500 grams) or lower; or
(B) Gastrointestinal anomaly,
				  metabolic/digestive disorder, or recovery from intestinal surgery where
				  digestive needs require additional support; or
(C) Diagnosed failure to thrive; or
(D) Formula intolerance with either
				  documented feeding difficulty or weight loss; or
(E) Infant hypoglycemia; or
(F) Congenital heart disease; or
(G) Pre or post organ transplant;
				  or
(H) Other serious health
				  conditions where the use of donor human breast milk has been deemed medically
				  necessary and will support the treatment and recovery of the infant as
				  reflected in the medical records or by a physician (MD or DO), physician's
				  assistant, or advanced practice nurse.
(5) For full guidelines, including the
				  medically necessary criteria, please refer to
www.okhca.org/mau
.