An Argument for Coverage of Lactation Consultation
A while back I published a bit about how to get insurance appeals approved. So here’s a specific example. This regards a young woman who delivered her first infant and was having trouble breastfeeding. After discharge, her physician recommended home lactation consultation services, which her insurer denied as not medically necessary. The patient’s policy did cover “skilled” medically necessary home health service , but not “custodial” care, defined as care meant for ongoing maintenance or assistance with daily living.
So here’s an answer to that (nonsense).
Typically, home health services are provided because the patient cannot leave their home to obtain those services, but lactation consultation is a different issue. Lactation services are either provided in the hospital while the patient is inpatient, or in the home after discharge. Most communities do not have facility to provide lactation consultation on an outpatient basis, other than through various licensed or unlicensed practitioners such as doulas or (some) midwives. As such, once a patient has left the hospital home health is the best option for this service, for most patients.
Furthermore, the provided policy does not specifically address lactation consultation specifically as either being a skilled service or a custodial service. If it were a skilled service and medically necessary, it would be covered.
While lactation consultation is not specifically addressed in plan policy, skilled services are defined as:
“A health service is determined to be skilled based upon whether or not clinical training is necessary for the service to be delivered safely and effectively and on the need for physician-directed medical care. Examples of clinical training include registered nurse, licensed practical nurse, respiratory therapist, physical therapist, occupational therapist, and speech therapist. This list is not all-inclusive.”
Based on this definition, lactation consultation would be skilled. Lactation consultation requires a specific certification, typically given along with RN, CNM, or LPN licensure. It cannot be provided by relatively untrained people such as certified nursing assistants.
Custodial care is defined as :
* Non-health-related services, such as assistance in activities of daily living (examples
include feeding, dressing, bathing, transferring and ambulating) – this is not the case here. The specific activity at hand is breastfeeding, which is not an activity of daily living for the patient. “feeding” in the policy refers to the patient feeding herself, not her infan.
* Health-related services which do not seek to cure, or which are provided during
periods when the medical condition of the patient who requires the service is not
changing. – This service does seek to “cure” a problem, in this case the problem being inability to breastfeed.
* Services that do not require continued administration by trained medical personnel in
order to be delivered safely and effectively. – This service does require trained medical personnel, with specific education on lactation education.
As such, lactation consultation is not custodial care.
Medical necessity of breastfeeding is clearly established, as while bottle feeding is an option, breastfeeding has been shown to be of substantial benefit to the infant, both in physical (growth, neural development, immune development) and psychological (mother-infant bonding) areas.
Based on plan coverage documents the requested 2 visits should be covered as a skilled service for this patient, under the provided coverage Documents.
Academic OB/GYN 
Thanks for providing this. The argument for insurance coverage is especially relevant if the lactation consultant is an IBCLC, which requires extensive training and clinical hours. Unfortunately, not all lactation consultants are that well trained. I’m curious to know if the LC’s at your hospital have the IBCLC certification.
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Thank you for posting this! As a newly minted IBCLC I find this very helpful and may have cause to use it in the future. I did want to clarify one piece:
“Based on this definition, lactation consultation would be skilled. Lactation consultation requires a specific certification, typically given along with RN, CNM, or LPN licensure. It cannot be provided by relatively untrained people such as certified nursing assistants.”
Becoming an IBCLC is a specific certification, typically with hundreds to thousands of hours of training required along with education from an approved provider. Because of the way the training requirements are set up, the people who find it easiest and most affordable to become IBCLCs are generally people with clinical certifications such as CNMs, RNs, MDs, RDs, etc. However, while the educational requirements will be changing somewhat in 2012, they have never required a specific level of clinical certification and will not in the foreseeable future. A CNA could become an IBCLC; so could someone with an MPH (right here!), or a JD or MS – or a BFA for that matter. Starting in 2012 all new IBCLC candidates will be required to complete coursework fairly similar to prerequisites for nursing school in addition to their lactation-specific education, but still will not need to have any specific clinical degree to sit the exam.
I hope this doesn’t change your opinion of IBCLCs! I think it strengthens our profession that an IBCLC is an independent credential, not an add-on certification to another clinical degree. Just as you don’t have to have a specific college major to go to med school and become an MD, you can become an IBCLC coming from any background – as long as you complete the required prereqs and training. An IBCLC is most certainly not providing custodial care, whether the IBCLC was originally a CNA or not.
Thank you again for this post and your support for fair reimbursement of needed lactation services. The reimbursement issue is endlessly frustrating and it’s good to know there are physicians out there who will help their patients access lactation services when they need them the most.
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Excuse me while I go pound my head against a brick wall. Deny LC services = more health care costs in a child (asthma, allergies, obesity). But our system does not value health and well being above the short term bottom line, that much is clear.
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You’re right, but insurance companies don’t make individual denials and approvals based on this. At a high level, they are creating policies that try to maximize services delivered and ultimate good from those services. At a low level, they are just looking at cases and seeing whether they meet coverage guidelines. These low level decisions don’t have anything to do with cost, and on appeal cost is generally not a consideration.
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But they sure make global policies on it. In this day and age lactation services should absolutely be covered. Another prime example of the “fail” that is the American “health care system”, which is really just multi-billion dollar companies making decisions to make more billions. Health, shmelf.
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I’m bookmarking this in case any of my friends are denied insurance coverage for LC visits. Just so I can have something to read to the insurance company over the phone…
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Oficial info – “The primary goal of LEC is to teach you to function as a lactation consultant. You will also be prepared to counsel and teach breastfeeding mothers.”
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I think by the time services were approved the mom would be formula feeding or found another way to get help. Read the post in kevinmd. Wonder what you might say about insurance company coverage of mental health benefits especially autism. ABA is the only empirically proven behavioral approach to improve outcomes, but it is almost never covered by insurance. Those who practice aba are certified and skilled. However, insurance companies leave it out of services covered with little chance of appeal. Ridiculous that the government has to pass laws to mandate coverage of a proven therapy as Massachusetts just did for Aba. I think it is easier to be empathetic to insurance companies if you are in a surgical specialty.
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