Provider Notice Issued 11/17/2020

Date:   November 17, 2020

To:       Enrolled Durable Medical Equipment and Supply Providers, Physicians and Advanced Practice Nurses

Re:      Coverage of Human Donor Breast Milk

This notice outlines the requirements for coverage of human donor breast milk, in accordance with Public Act 101-0511, effective January 1, 2020. Coverage for donor breast milk applies to persons under traditional Medicaid fee-for-service as well as a HealthChoice Illinois managed care plan.

Regardless of the child’s age, the criteria for coverage of pasteurized donated human breast milk per the Act is based upon a prescription from a licensed medical practitioner (i.e., physician, advanced practice nurse, physician assistant) and the following conditions:

1. The milk is obtained from a human milk bank that meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health and is enrolled as a provider in the Illinois Medical Assistance Program.
2. The infant’s mother is medically or physically unable to produce maternal breast milk or produce it in sufficient quantities to meet the infant’s needs, or the maternal breast milk is contraindicated. Pasteurized donated human milk can also serve as a bridge to availability of the mother’s milk as applicable in these select situations.
3.  The milk has been determined medically necessary for the infant and advantageous over commercially available formulas. 

For purposes of interpretation, the Department will use chronologic age for all infants born at or after 37 weeks estimated gestational age. Adjusted age will be used for all infants born prematurely before 37 weeks estimated gestational age up to chronologic age 12 months.

For infants with an adjusted age or chronologic age up to 6 months as applicable, at least one of the following must apply:

·        Birth weight below 1,500 grams

·        Presence of a congenital or acquired condition that increases risk for development of necrotizing enterocolitis

·         Active treatment of hypoglycemia

·         Presence of congenital heart disease

·         Infant is on list to receive an organ transplant or already has received one

·         Active treatment for sepsis

·         Presence of congenital or acquired condition for which use of human milk confers a medical advantage to support treatment and recovery.

For infants with an adjusted age or chronologic age 6 through 12 months as applicable, at least one of the following must apply:

·  Birth weight below 1,500 grams with a long term feeding or gastrointestinal condition that has arisen as a complication related to prematurity

·   Infant is on list to receive an organ transplant or already has received one

·   Presence of congenital or acquired condition for which use of human milk confers a medical advantage to support treatment and recovery

·   Diagnosis of spinal muscular atrophy. 

For participants 12 months of age or older, the following must apply:

·   The child has spinal muscular atrophy.

Prior Approval and Claim Coding

Prior approval for human donor milk is required. For Medicaid fee-for-service participants, suppliers must complete form HFS 1305, Questionnaire for Human Donor Milk, and submit it with the HFS 1409, Prior Approval Request form. Without the questionnaire the prior approval request will be returned as invalid. If the participant is enrolled in a managed care plan, please verify the prior approval requirements with the MCO.

Enrolled suppliers may bill for the donor milk under HCPCS code T2101 – Human Breast Milk Processing, Storage and Distribution. The DME Fee Schedule has been updated to include this code.

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for fee-for-service claims, or to the applicable managed care plan.

Kelly Cunningham

Interim Medicaid Administrator