Clinical UM Guideline


Subject:Neonatal Levels of Care
Guideline #:  CG-MED-26Current Effective Date:  10/14/2014
Status:RevisedLast Review Date:  08/14/2014

Description

Hospitals vary in the type of newborn care they provide. Not all facilities are able to provide all types of care needed for sick newborns. The American Academy of Pediatrics (AAP) has defined the levels of care required for the normal healthy newborn to the critically ill newborn. These levels of care correspond to the therapies and services provided in each nursery. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification. All levels of care described in this document are based upon clinical care needs and are not dependent upon the physical location of the infant within the health care facility or the name of the unit where the care is delivered.

A medically necessary neonatal level of care indicates the intensity of services needed or rendered based on an infant's clinical status and is not the same as AAP levels of nursery designation, which are based on the facility clinical service capabilities.

Clinical Indications

Medically Necessary:

Admission to and continued stay in appropriate neonatal levels of care are considered medically necessary for the following indications: 

General Nursery or Well-Baby Nursery:

This level of care is for healthy neonates who are physiologically stable and under routine evaluation and observation in the immediate post-partum period. Infants weighing 2000 grams or more at birth and clinically stable infants at 35 weeks gestational age or greater may be cared for in a well-baby nursery. This is not a neonatal intensive care level. Phototherapy, intravenous (IV) fluids and antibiotic therapy are not appropriate for this level of care.

Examples of types of services neonates receive or clinical conditions managed at this level of care are:

  1. Oral (nipple) feedings for asymptomatic hypoglycemia not requiring subsequent IV therapy;
  2. Routine tests, examples include, but are not limited to, bilirubin, blood glucose, blood type and Coombs, direct antiglobulin test (DAT), complete blood count (CBC) or oximetry.

Level I Surveillance i.e., 'Special Care Nursery':

This level of care covers neonates who are medically stable but require surveillance/care at a higher level than provided in the general nursery.

Examples of types of services neonates receive or clinical conditions managed at this level are:

  1. Apnea/Bradycardia
    1. Oral pharmacologic therapy for a baby who has been apnea-free for at least 72 hours; or
    2. Surveillance without pharmacological intervention and 48 hours or more since last episode requiring intervention.
  2. Diagnostic work-up/surveillance, on an otherwise stable neonate where no therapy is initiated;
  3. Hyperbilirubinemia requiring phototherapy;
  4. Infants transferred from a higher level of care who are physiologically stable, breathing room air, in an open crib, and taking either no medications or on a stable or declining dose of oral medications and requiring observation to document successful nipple feeding;
  5. Initial sepsis evaluation (CBC, blood culture for an asymptomatic neonate);
  6. Isolette/warmer for observation or convenience of access (adjunctive therapy) and no other level II, III or IV criteria present;
  7. IV fluids at low to moderate rates (generally less than 50 ml/kg/day) in stable infants who are being weaned off of IV fluids and without other clinical conditions qualifying for a higher level of care (LOC);
  8. Services rendered for Neonatal Abstinence Syndrome (withdrawal) scores less than 8;
  9. Services rendered to growing premature infant without supplemental oxygen or IV fluid needs or environmental control needs (other than blankets, cap, swaddling, etc.);
  10. Services to improve poor breast or bottle feeding that is advancing to full volume feeds.

Level II Neonatal Intensive Care:

Newborns admitted or treated at this level are those with physiological immaturity combined with medical instabilities.

Examples of types of services neonates receive or clinical conditions managed at this level of  care are:

  1. Infants born 32 weeks gestation or greater and under 35 weeks gestation or infants weighing 1500 grams or more who have physiologic immaturity and who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis.
  2. Apnea/Bradycardia
    1. Apnea/Bradycardia episode requiring vigorous stimulation; or
    2. Oral pharmacologic treatment for apnea and/or bradycardic episodes when last episode requiring intervention was less than 72 hours ago.
  3. Feedings for 30 minutes or less via an orally or nasally inserted tube, for example nasogastric, nasojejunal, or gastrostomy tube.
  4. Incubator/Warmer
    1. Documented need for environmental control via an incubator/warmer for thermoregulation; or
    2. Physiologically stable infants in the process of being weaned from an incubator/warmer to an open crib.
  5. IV Therapy
    1. IV fluids (inclusive of hyperalimentation) at high infusion rate (generally greater than or equal to 50 ml/kg/day); or
    2. IV heparin lock medications; or
    3. IV medications in a physiologically/clinically stable infant via PICC line or peripheral IV; or
    4. IV treatment of hypoglycemia.
  6. Respiratory support
    1. High-flow nasal cannula with flow less than or equal to 2 liters per minute or continuous positive airway pressure (CPAP) less than or equal to 4 cm H2O pressure; or
    2. Supplemental oxygen via oxygen hood or nasal cannula when effective fraction of inspired oxygen (FiO2) of less than or equal to 40% is sufficient to maintain acceptable blood oxygen saturation (SaO2); or
    3. Infants transitioning to home on a home ventilator awaiting family teaching and/or placement availability.
  7. Sepsis
    1. Initial sepsis evaluation (CBC, blood culture, and other blood tests or cultures) for an asymptomatic neonate and antibiotic treatment pending laboratory and/or culture results; or
    2. Sepsis suspected or documented with treatment (IV/IM [intramuscular] therapies) beyond the initial 48 hours of treatment.
  8. Services rendered for Neonatal Abstinence Syndrome (NAS) when the score is greater than or equal to 8.

Level III Neonatal Intensive Care:

This level of care is directed at those neonates that require invasive therapies and/or are critically ill with respiratory, circulatory, metabolic or hematologic instabilities and/or require surgical intervention with general anesthesia. 

Examples of types of services neonates receive or clinical conditions managed at this level of care are:

  1. Apnea and/or Bradycardia
    1. Episodes requiring IV pharmacologic treatment; or
    2. Self-refilling bag valve unit resuscitation ("bagging"); or
    3. Other intervention beyond vigorous stimulation (for example CPAP).
  2. Blood or blood product transfusion;
  3. Chest tube;
  4. Exchange transfusion, partial or complete and up to 48 hours after exchange transfusion dependent on clinical stability;
  5. Feedings greater than 30 minutes via an orally or nasally inserted tube, for example, nasogastric, orogastric, nasojejunal, or gastrostomy tube;
  6. Hemodynamic instability (including hypertension)
    1. Invasive hemodynamic monitoring and CNS pressure monitoring; or
    2. Requiring IV volume bolus therapy and/or inotropic or chronotrophic drugs, Ca++ channel blockers, and IV prostaglandin therapy.
  7. Infants less than 32 weeks gestational age or less than 1500 gms birth weight for the first 24 hours of life;
  8. IV Therapy
    1. Inborn error of metabolism requiring IV therapy or specialized formula until tolerating full enteral feeds; or
    2. IV bolus or continuous drip therapy for severe physiologic/metabolic instability; or
    3. Metabolic acidosis or alkalosis or electrolyte imbalance requiring IV therapy; or
    4. Seizures requiring IV therapy (this criterion includes IV glucose administration for seizures caused by hypoglycemia); or
    5. Short bowel or "dumping" syndrome requiring total parenteral nutrition (TPN) at 50 or greater ml/kg/day.
  9. Respiratory Services
    1. High-flow nasal cannula with flow greater than 2 liters per minute or CPAP greater than 4 cm H2O pressure; or
    2. Positive pressure ventilator assistance with intubation and 24 hours post-ventilator care; or
    3. Supplemental oxygen via oxygen hood or nasal cannula when effective FiO2 of greater than 40% is required to maintain acceptable SaO2 or neonate is intubated (Note: Intubation in the delivery room [DR] when the endotracheal tube is removed prior to leaving the DR or brief intubation for administration of surfactant or deep tracheal suctioning does not meet level III criteria for intubation); or
    4. Infants on chronic ventilators who are not sufficiently stable to transition to home ventilators/homecare or long term care.
  10. Surgical conditions requiring general anesthesia and two days post-op;
  11. Therapies for retinopathy of prematurity (ROP);
  12. Umbilical Artery Catheters (UACs), Peripheral Artery Catheters (PACs), Umbilical Vein Catheters (UVCs) and/or Central Vein Catheters (CVCs) when used for active monitoring or arterial or venous pressures.

Level IV Neonatal Intensive Care:

This level of care covers critically ill neonates with respiratory, circulatory, metabolic or hemolytic instabilities as well as conditions that require surgical intervention. 

Examples of types of services neonates receive or clinical conditions managed at this level of care are:

  1. Extracorporeal membrane oxygenation (ECMO)/nitric oxide (NO);
  2. High frequency ventilation (HFV) used when conventional mechanical ventilation fails;
  3. Hypothermia therapy for hypoxic-ischemic encephalopathy-total body or selective head cooling;
  4. Pre and post-surgical care for severe congenital malformations or acquired conditions such as gastroschesis, ventricular septal defect (VSD) or other heart defects or bowel perforation, that require the use of advanced technology and support.

Not Medically Necessary:

Admission to and continued stay in appropriate neonatal levels of care are considered not medically necessary when the above criteria are not met.

Coding

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Discussion

Hospitals with obstetric services must also care for the newborn. In most cases, newborns do not require care beyond that of a general nursery. However, newborn complications can occur even when an uneventful birth is anticipated. It is important that facilities have equipment and capabilities to address these events or the process to stabilize and transport the ill newborn to a facility that does. The high-risk neonate is a newborn who has encountered an event in prenatal, perinatal, or postnatal life that leads to a high probability of manifesting a physiological or psychological deficit that requires admission to a neonatal intensive care unit (NICU).

Complications requiring a NICU admission can occur in premature and term infants. Infants born between 37 and 42 weeks of pregnancy are considered full term. Those born before 37 completed weeks of pregnancy are considered premature or late preterm. A late preterm infant is a premature baby born between 34 and 36 weeks gestational age. This is relatively close to full term, which is 37 weeks or greater (Engle, 2007).

About 12% of babies in the United States are born preterm. Of those, the majority (70%) of premature babies are born between 34 and 36 weeks of gestation, 12% are born between 32 and 33 weeks gestation, 10% between 28 and 31 weeks and 6% at less than 28 weeks gestation.

Newborn complications include, but are not limited to:

The American Academy of Pediatrics (AAP, 2012a) issued a policy statement outlining the designations of levels of neonatal care to distinguish and standardize newborn care capabilities offered by hospitals. The AAP designations consist of levels I-IV and encompass all newborn care, from general care of the healthy newborn to care of the critically ill newborn. Each level reflects the minimal capabilities, functional criteria, and provider type required.

However, examples of medically necessary levels of neonatal care (such as hyperalimentation and treatment of apnea/bradycardia) noted in this document indicate the intensity of services needed or rendered based on an infant's clinical status as described by expert clinical input and are not the same as AAP designations, which are based on the facility clinical service capabilities.

The AAP (2012b) released a neonatal drug withdrawal report indicating the predominant tool used in the United States to quantify the severity of neonatal withdrawal is the modified Neonatal Abstinence Scoring System. The system assigns a cumulative score based on the interval observation of 21 items relating to signs of neonatal withdrawal. Signs of neonatal withdrawal scored on the tool include central nervous system disturbances, metabolic/vasomotor/respiratory disturbances, and gastro-intestinal disturbances.

References

Peer Reviewed Publications:

  1. Behrman R, Kliegman R, Jenson. Nelson Textbook of Pediatrics, 17th ed., 2004 Saunders.
  2. Phibbs CS, Baker LC, Caughey AB, et al. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med. 2007; 356(21):2165-2175.
  3. Tyson JE, Parikh NA, Langer J, et al. Intensive care for extreme prematurity--moving beyond gestational age.  N Engl J Med. 2008; 358(16):1672-1681. 

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Pediatrics (AAP), Committee on Fetus and Newborn. Levels of neonatal care. Pediatrics 2012a; 130(3):587-597. Available at: http://pediatrics.aappublications.org/content/130/3/587.full.pdf. Accessed on July 14, 2014.
  2. Engle WA, Tomashek KM, Wallman C; Committee on Fetus and Newborn, American Academy of Pediatrics. "Late-preterm" infants: a population at risk. Pediatrics. 2007; 120(6):1390-1401. Available at: http://pediatrics.aappublications.org/cgi/reprint/120/6/1390. Accessed on July 14, 2014.
  3. Hudak ML, Tan RC; Committee on Drugs; Committee on Fetus and Newborn; American Academy of Pediatrics. Neonatal drug withdrawal. Pediatrics. 2012b; 129(2):e540-560. Available at: http://pediatrics.aappublications.org/content/129/2/e540.full.pdf+html. Accessed on July 14, 2014.
Websites for Additional Information
  1. March of Dimes. Preterm birth. 2012. Available at: http://www.marchofdimes.com/baby/premature_indepth.html. Accessed on July 14, 2014.
  2. National Institutes of Health (NIH). Preterm Labor and Birth. 2013. Available at: http://www.nichd.nih.gov/health/topics/preterm/Pages/default.aspx. Accessed on July 14, 2014.
Index

Levels of Care
Neonatal Intensive Care
NICU

History
StatusDateAction
Revised08/14/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Examples for levels of care I, II, and III in medically necessary statement updated. Discussion, Links in Reference and Websites sections updated.
Revised02/13/2014MPTAC review. Examples for levels of care in medically necessary statement updated. Not medically necessary statement added. Discussion and Reference sections updated.
Revised08/08/2013MPTAC review. Position statement updated with "and continued stay in."
Revised02/14/2013MPTAC review. Position statement updated with 2012 AAP levels. Description, Discussion and Reference sections updated.
Reviewed02/16/2012MPTAC review. References updated.
Reviewed02/17/2011MPTAC review. References updated.
Reviewed02/25/2010MPTAC review. References updated.
Reviewed02/26/2009MPTAC review. Case management section deleted, references updated.
Reviewed02/21/2008MPTAC review. References updated.
Revised03/08/2007MPTAC review. Criteria revised. References updated. 
Revised06/08/2006MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger
Organizations 
Last Review
Date
Guideline
Number
Title

Anthem, Inc.

  None
WellPoint Health Networks, Inc.12/01/05GuidelineNeonatal Levels of Care