Current through Vol. 42, No. 1, September 16, 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.
(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;
(C) Donor
human breast milk request form;
(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.
