Clinical UM Guideline
|Subject:||Home Phototherapy Devices for Neonatal Hyperbilirubinemia|
|Guideline #:||CG-DME-12||Current Effective Date:||01/13/2015|
|Status:||Reviewed||Last Review Date:||11/13/2014|
This document addresses the use of home phototherapy and the devices used for the treatment of neonatal jaundice that is physiologic (that is, non-pathologic) in nature. In utero, the fetus requires larger amounts of hemoglobin for oxygenation. After birth, the need is reduced and hemoglobin is rapidly destroyed, producing increased levels of bilirubin. Jaundice results when the neonate's liver is unable to efficiently clear the accumulating bilirubin. Neonatal jaundice is a common occurrence and is frequently treated in the home setting. Infants with very high levels of bilirubin may be managed in the inpatient setting.
Home phototherapy devices for neonatal hyperbilirubinemia are considered medically necessary when:
Not Medically Necessary:
Home phototherapy devices for neonatal hyperbilirubinemia are considered not medically necessary when the criteria above have not been met.
Home phototherapy devices for neonatal hyperbilirubinemia are considered not medically necessary when more than one phototherapy device (intensive phototherapy) is used in the home setting.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. 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.
|E0202||Phototherapy (bilirubin) light with photometer|
|S9098||Home visit, phototherapy services (e.g., Bili-liteTM), including equipment rental, nursing services, blood draw, supplies, and other services, per diem|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
Hyperbilirubinemia is the most common condition requiring medical attention in newborns. A total of 50% of term neonates and 80% of preterm neonates develop jaundice in the first week of life. The jaundiced skin and sclera in newborns is the result of accumulation of unconjugated bilirubin. In most infants, unconjugated hyperbilirubinemia reflects a normal transitional phenomenon. However, in some infants, serum bilirubin levels may rise excessively, which can be a cause for concern as unconjugated bilirubin can be neurotoxic. Therefore, the presence of neonatal jaundice frequently requires diagnostic evaluation and treatment.
In the hospital setting, phototherapy is delivered by exposing the infant to fluorescent light. When this type of light source is used, the infant's eyes are protected from the lights with a mask. The infant is positioned in an incubator wearing only a diaper, exposing as much of the infant's skin surface as possible to the light source. For those infants with very high bilirubin levels, intensive phototherapy may be used. This type of phototherapy employs two light sources such as fluorescent and fiber optic light.
In the home setting, phototherapy is accomplished by using a blanket or a neck ring that emits fiber optic light. This light is directed below the infant's head and is less intense than fluorescent light; therefore, masking the infant's eyes is not necessary. The infant can also be fed without interrupting therapy. If the serum bilirubin level is rising in spite of home phototherapy, the infant may be treated with intensive phototherapy in the inpatient setting.
The American Academy of Pediatrics (AAP) guideline for the Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation (2004) defines "intensive phototherapy" as "irradiance in the blue-green spectrum (wavelengths of approximately 430-490 nm) of at least 30 µW/cm² per nm (measured at the infant's skin directly below the center of the phototherapy unit) and delivered to as much of the infant's surface area as possible." The guideline indicates:
Because the devices available for home phototherapy may not provide the same degree of irradiance or surface-area exposure as those available in the hospital, home phototherapy should be used only in infants whose bilirubin levels are in the "optional phototherapy" range; it is not appropriate for infants with higher bilirubin concentrations. As with hospitalized infants, it is essential that serum bilirubin levels be monitored regularly.
The guideline also indicates there is no standard for discontinuing phototherapy. The total serum bilirubin (TSB) level for discontinuing phototherapy depends on the age of the infant when phototherapy is initiated and the cause of the hyperbilirubinemia. However, phototherapy is usually discontinued when the serum bilirubin level falls below 13 to 14 mg/dL.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Reviewed||11/13/2014||Medical Policy & Technology Assessment Committee (MPTAC) review. No change to clinical indications section.|
|Reviewed||11/14/2013||MPTAC review. No change to clinical indications section. References updated.|
|Revised||11/08/2012||MPTAC review. Added not medically necessary statement for when medically necessary criteria have not been met. Updated Reference section.|
|Reviewed||11/17/2011||MPTAC review. No change in criteria. Coding and References updated.|
|Reviewed||11/18/2010||MPTAC review. No change in criteria. References updated.|
|Reviewed||11/19/2009||MPTAC review. Removed Place of Service/Duration table. Updated Discussion/General Information and References.|
|Reviewed||11/20/2008||MPTAC review. References updated.|
|Reviewed||11/29/2007||MPTAC review. Description and references updated.|
|Revised||12/01/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Last Review Date||Document Number||Title|
|WellPoint Health Networks, Inc.||12/02/2004|
Home Phototherapy Devices for Neonatal Hyperbilirubinemia