Understanding Lactation and Insurance Coverage
The following covers overall info for both in-network and out-of-network patients - but see below for Aetna-specific information (and note that much of that info is sometimes relevant for other policies)
Lactation visits are covered as preventative care by both Federal (the Affordable Care Act (ACA) and the State of NJ (other than some “grandfathered” policies). However - because many insurance companies do not effectively inform clients (or sometimes their own representatives!) about lactation coverage, here are recommendations for you to follow:
Before your visit:
Call your insurance to ask about coverage. My NPI is 1205245537. For out-of-network visits, I typically use diagnosis codes Z39.1 and procedure code S9443 (again see below for Aetna). If they don’t cover S9443 to my full rate (see main FAQ page), ask about their coverage for the codes 99404 and/or 99204.
Ask for a list of in-network IBCLCs. If there are none that are in your area, ask for an out-of-network exception (sometimes called gap exceptions, NAP, or other names).
If you are limited to a low number of visits, request more coverage. It may help to get a note from your and/or your babies doctor - this should including diagnosis codes including but not limited to Dx P92.9 (Feeding problem of newborn), Dx Z39.1 (Lactation issues, mother) and Q38.1 (Ankyloglossia/tongue-tie).
Things to watch out for:
Being told that they only cover lactation with your OB or pediatrician. They are wonderful doctors, but they are not lactation specialists.
You should NOT need pre-approval or proof of medical necessity (feeding a baby and protecting your breast health is a medical necessity!).
If you submit your claim and it’s not covered:
Call and explain that lactation is preventative care (and cite the laws, etc) - very often they will say “oops” and cover the visit.
If this does not work, re-ask about the codes listed above (in case they may be covered more effectively in your case) and also go to the next section…
If you feel that you are not getting the help and/or coverage you deserve:
Ask for a patient representative who can help manage your case.
Tell them that you will file a complaint (and please do!) with the State of NJ office of Banking and Insurance. (Note - if you are not from NJ, many other states have similar offices, so look those up!)
From the National Women’s Law Center - “New Benefits from Breastfeeding Moms: Facts and Tools to Understand Your Coverage under the Health Care Law” and “I still have to pay out-of-pocket for my Lactation Consultation”
And, also use the info from there other pages, which all have good overviews of insurance coverage - The Lactation Place, Lucky Baby Lactation, and Rachel O’Brien (Rachel also has two more articles - one, two). Much of the info is complementary to what I have here, but worth checking out in case they have added new/more helpful info.
And - even if your insurance company does the wrong thing and does not reimburse or cover enough visits, or if you just decide it’s too much effort - please know that lactation visits have tremendous value even if you pay for them - potentially saving the costs of formula, future oral therapies, dental issues, etc.
Aetna's Lactation Coverage
(also relevant for many other in-network policies)
The real story behind Aetna's "6 covered" lactation visits can be complex, and not all visits may be completely free. Here's a comprehensive breakdown:
Aetna's "6 fully covered" visits are limited:
The 6 "covered" entities counted by Aetna are for ONE billing code (S9443), covering only about 1/4 of my total fee (see the main FAQ page for examples of visit fees if you are not in-network)
Lactation visits are lengthy and involve multiple patients:
Each visit typically lasts around 1.5-2 hours and involves both the lactating parent and the baby (or babies in the case of multiples), which means additional codes are needed to represent comprehensive care. For example, a 2-hour visit uses codes 99404, S9443 (and sometimes 96161) for the parent, and 99404, S9443 for the baby.
Potential reduction in coverage:
Some policies may count each use of the S9443 code (in the example above - one for parent, one for baby) as a separate visit, effectively reducing full coverage from 6 to 3 visits. (The visits are still partially covered though!)
Baby's coverage varies:
The Affordable Care Act (ACA) covers lactation as preventative care for the parent, but coverage for baby varies among insurance policies - some paying in full for the baby, while others trigger deductibles, co-pays, or co-insurance.
New Aetna coding changes (March 2024) mean it’s more likely that there will be some out-of-pocket expense for baby.
Factors that result in additional charges:
Having taken online lactation classes or previous lactation visits (even prenatal ones offered by Aeroflow and other companies that help get pumps through insurance) likely billed the S9443 code each time - reducing your remaining number of covered visits.
If only the parent has in-network insurance, or the visit is solely for the parent, additional charges will apply.
HMO plans may require referrals from both the parent's and baby's healthcare providers for full coverage.
Certain plans, like the Princeton Student plan or NJ hospital-based plans, may deny specific codes normally covered by Aetna.
Take action:
Contact your insurance company to advocate for more coverage. For example, most people are completely unaware that companies like Aeroflow (and others) used up coverage for their prenatal classes. You have the right to ask for those claims to be reversed, especially if you were unaware that they were used!
Customer service representatives may initially state that the claims were coded incorrectly, but be firm and reference the information provided here (and at the top of the page).
Ask for a health concierge to help you (many polices provide them - ask member services). They help navigate appeals, and work with both you and the provider at the same time.
If necessary, escalate your call to a supervisor to support your case.
For each visit, I will submit the claim and - if claims are not covered as they should be - can sometimes do an appeal. Any fees that are not covered will be billed for using your credit card on file. I can provide a good-faith estimate before your visits - just ask!