Clinical UM Guideline
|Subject:||Neonatal Levels of Care|
|Guideline #:||CG-MED-26||Current Effective Date:||08/12/2013|
|Status:||Revised||Last Review Date:||08/08/2013|
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.
Admission to and continued stay in appropriate neonatal levels of care are considered medically necessary for the following indications:
General Nursery Observation (Level I AAP):
This level of care covers healthy neonates who are physiologically stable and under routine evaluation and observation in the immediate post-partum period. This is not a neonatal intensive care unit level of care. This level of care may include routine bilirubin and blood glucose testing.
Level I Surveillance i.e., 'Special Care Nursery' (Level I AAP):
This level of care covers neonates who are medically stable but require surveillance/care at a higher level than provided in the general nursery. Types of services neonates receive at this level are:
Level II Neonatal Intensive Care Unit (Level II AAP):
Newborns admitted to this unit are those with physiological immaturity combined with medical instabilities. Examples of the care at this level are:
Level III Neonatal Intensive Care Unit (Level III AAP):
This level of care is directed at those neonates that require invasive therapies such as:
Level IV Neonatal Intensive Care Unit (Level IV AAP):
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 services provided at this level are:
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.
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).
The American Academy of Pediatrics (AAP) 2012 policy statement is directed at facilities that offer newborn care. The AAP policy statement outlines the designations of levels of care that would distinguish and standardize the newborn care capabilities offered by hospitals. These designations 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 (AAP, 2012).
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 percent 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:
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Web Sites for Additional Information|
Levels of Care
Neonatal Intensive Care
|Revised||08/08/2013||Medical Policy & Technology Assessment Committee (MPTAC) review. Position statement updated with "and continued stay in".|
|Revised||02/14/2013||MPTAC review. Position statement updated with 2012 AAP levels. Description, Discussion and Reference sections updated.|
|Reviewed||02/16/2012||MPTAC review. References updated.|
|Reviewed||02/17/2011||MPTAC review. References updated.|
|Reviewed||02/25/2010||MPTAC review. References updated.|
|Reviewed||02/26/2009||MPTAC review. Case management section deleted, references updated.|
|Reviewed||02/21/2008||MPTAC review. References updated.|
|Revised||03/08/2007||MPTAC review. Criteria revised. References updated.|
|Revised||06/08/2006||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organizations||Last Review Date||Guideline Number||Title|
|WellPoint Health Networks, Inc.||12/01/05||Guideline||Neonatal Levels of Care|