Understanding Lactation and Insurance Coverage

This section provides general information for both in-network and out-of-network patients. Specific details for Aetna coverage can be found below, but much of the information may also apply to other insurance policies.

Lactation visits are typically covered as preventative care under both federal law (Affordable Care Act/ACA) and New Jersey state regulations (except for some “grandfathered” plans). However, since many insurance companies don’t effectively communicate about lactation coverage, here are some steps to help you navigate your insurance:

Before Your Visit:

  • Call your insurance company and ask about lactation coverage. You can use this NPI 1255873527 and 1316670367. For out-of-network visits, I usually use diagnosis code Z39.1 and procedure code S9443. If they don’t cover the S9443 code at our full rate, inquire about coverage for codes 99404 and 99204.

  • Request a list of in-network IBCLCs. If no providers are available nearby, ask for an out-of-network exception (sometimes called gap exceptions or NAP).

  • If your plan limits the number of visits, request additional coverage. A note from your or your baby’s doctor using diagnosis codes like P92.9 (Feeding problems of newborn), Z39.1 (Lactation issues), or Q38.1 (Ankyloglossia/tongue-tie) can be helpful.

Important Considerations:

  • Be cautious if told that lactation care is only covered through your OB or pediatrician. While they are valuable members of your healthcare team, they aren’t specialists in lactation. We are with our patients for 60-90 min for most sessions while other providers are unable to dedicate this time for these services.

  • You should not need prior authorization or proof of medical necessity—feeding your baby and protecting your breast health are medical necessities!

If Your Claim Isn’t Covered:

  • Call your insurance provider and remind them that lactation care is classified as preventative care under federal and state laws. Often, this resolves the issue.

  • If that doesn’t work, inquire about the codes mentioned above, as they may apply more effectively.

If You Encounter Problems:

  • Please speak with a supervisor and ask to escalate the call. Keep all reference numbers given and names of associates you speak with.

  • Let them know you plan to file a complaint with the New Jersey Department of Banking and Insurance (or a similar office in your state).

  • Check resources from organizations like the National Women’s Law Center, which offers helpful guides on understanding lactation coverage under the ACA.

Even if your insurance denies coverage or the process becomes overwhelming, remember that lactation consultations have tremendous value. We can help save costs in the long run by avoiding formula expenses or future medical treatments like oral therapies or dental care.

Aetna Lactation Coverage
(This may also apply to other in-network policies.)

Aetna’s promise of “six fully covered lactation visits” can be more complex than it seems. Here’s what you need to know:

  • Aetna’s coverage is often limited to six visits using billing code S9443, which only accounts for about a quarter of my full fee. You can find more details on visit fees on my main FAQ page.

  • Lactation visits are typically lengthy (1-2 hours) and involve both the parent and baby, meaning multiple billing codes are often necessary. For a 1-2 visit, we might bill using codes 99404, S9443, and sometimes 96161 for the parent, plus 99404 and S9443 for the baby.

  • Some plans may count each S9443 code used (for both parent and baby) as a separate visit, effectively reducing coverage from six to just three visits, though partial coverage still applies.

  • Baby coverage can vary. While the ACA ensures lactation coverage for the parent, baby’s coverage is more dependent on individual policies, which may involve deductibles or co-pays.

  • Recent changes to Aetna coding (as of March 2024) may mean additional out-of-pocket costs for the baby.

Potential Issues:

  • Previous lactation visits, including prenatal ones (e.g., through Aeroflow or similar services), may have already used your S9443 code allocation, leaving fewer visits available.

  • If only the parent has in-network insurance or if the visit is focused solely on the parent, additional fees may apply.

  • Certain plans, like those offered by Princeton University or hospital-based policies in NJ, may deny specific codes normally covered by Aetna.

What You Can Do:

  • Contact your insurance provider to advocate for more coverage. If you weren’t informed that previous visits used your S9443 coverage, you can request that those claims be reversed.

  • If you’re told that claims were coded incorrectly, push back by referencing the information provided here.

  • Ask to speak with a health concierge, if available, to help you with appeals and coordinating between you and your provider.

  • Again escalate to a supervisor if necessary.

For each visit, we will submit your claim. If coverage issues arise, we can sometimes help with the appeals process. Any fees not covered will be charged to the credit card on file or you can choose to send via venmo or Zelle.