Library: Policy

317:30-5-211.29. Donor human breast milk

Revised 11-4-22

(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

(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

(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.

(d) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-5-211.20(c). Documentation must include:

(1) A prescription from a contracted provider [a physician (MD or DO), physician's assistant, or advanced practice nurse]. The prescription must include but not limited to:

(A) Name of infant, address and diagnoses;

(B) Parent name and phone number or email;

(D) Number of ounces per day, week, or month needed; and

(E) Prescriptions must be written on a prescription notepad and signed off by an authorized provider.

(F) For full guidelines, please refer to www.okhca.org/mau.

(2) Donor human breast milk is excluded from requiring a CMN.

(e) Reimbursement. Donor human breast milk is reimbursed as follows:

(1) When donor human breast milk is provided in the inpatient setting, it will be reimbursed within the prospective Diagnosis Related Group (DRG) payment methodology for hospitals as authorized under the Oklahoma Medicaid State Plan.

(2) When donor human breast milk is provided in an outpatient setting as a medical supply benefit, it will be reimbursed as a durable medical equipment, supplies, and appliances (DME) item in accordance the OHCA fee schedule.