Want Insurance to Pay You Back for a Lactation Visit? Here’s What You Can Do to Give Yourself the Best Chance

It’s incredibly frustrating that insurance doesn’t always work the way it should – especially when new parents have enough on their plates. You deserve to be reimbursed for the care you’re entitled to, and I’m hoping to offer some tools to make that process as straightforward as possible.

Before Your Visit:

1. Call your insurance company. Ask:
   • Do they cover lactation visits?
   • Are there any in-network lactation consultants nearby?
   • If not, ask if they’ll cover an out-of-network visit (sometimes called a “gap exception”).
2. Give them the codes I use for billing and ask if they cover them fully:
   • Diagnosis code: Z39.1 (encounter for care of lactating mother)
   • Procedure code: S9443 (lactation help)

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Common Pushback & Responses You Can Give:

• If they say only your OB or pediatrician can provide care:
  • Express strongly that these providers are not feeding specialists.
• If they say you need approval ahead of time:
  • Explain that lactation care is part of preventive health and according to the affordable care act it is guaranteed to be covered.

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After Your Visit:

If the insurance company denies your claim:

1. Call them again. Tell them lactation care is preventive care under the law.
2. Ask to speak with a patient rep or supervisor.
3. Ask if other codes are covered better.
4. Say you’ll file a complaint with your state’s insurance department (in NY it’s the Department of Financial Services – https://www.dfs.ny.gov/complaint).

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Other Tips:

• Ask for a “health concierge” if your plan has one—they can help with appeals.
• Ask your insurance to undo (reverse) any claims you didn’t know about or didn’t use.
• If someone tells you the codes were wrong, stay calm. Many reps don’t understand how lactation billing works.
• Here are some other websites that may give more detailed or updated information:
  • https://www.rachelobrienibclc.com/blog/how-to-get-reimbursed-for-a-ibclc-home-visit/
  • https://www.thelactationplace.com/insurance-information/
  • https://www.lactationsolutionsofprinceton.com/insurance
• Keep me updated on how this is all going! The landscape of insurance is constantly changing and I can support families better the more that I hear about what is currently working or not working.

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Even if your insurance company doesn’t reimburse you fairly,
limits the number of visits, or you decide the process just feels like too much,
please know that lactation support is still incredibly valuable.
Getting help early can make a meaningful difference,
potentially reducing future costs (formula, orthodontia, or other therapies),
and giving you and your baby a smoother start.