Clinical Policy: Phototherapy for Neonatal Hyperbilirubinemia

Reference Number: CP.MP.150
Date of Last Revision: 01/25
[Coding Implications](Coding Implications)
[Revision Log](Revision Log)

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.

Description

This policy details medical necessity criteria for home phototherapy for the treatment of neonatal hyperbilirubinemia. Almost all newborns will develop total serum bilirubin (TSB) levels greater than the upper limit of normal for adults, 1 mg/dL. Increasing TSB can cause jaundice, and newborns with severe hyperbilirubinemia are at risk for developing acute neurotoxicity as bilirubin crosses the blood-brain barrier. Acute bilirubin-induced neurologic dysfunction (BIND) can have chronic and permanent neurologic effects, termed kernicterus. Thus, screening for hyperbilirubinemia should be conducted on all infants prior to discharge.¹

*Note: The TSB home phototherapy table above allows for conservative TSB levels to align with the lower age limit in hours provided in the age ranges for inpatient criteria for hyperbilirubinemia (see section II).

II. It is the policy of Centene Corporation that when criteria for home phototherapy are met, inpatient phototherapy for hyperbilirubinemia is not medically necessary unless documentation of extenuating circumstances (including, but not limited to, expected lack of ability to adhere to therapy at home) is provided.

* Note:

• Infants should be admitted for inpatient phototherapy if the TSB concentration is more than 1 mg/dL above the American Academy of Pediatrics (AAP) guidelines phototherapy treatment threshold in the hyperbilirubinemia risk calculator at https://peditoools/bili2022/index.php. The values in Table 1 above offer phototherapy at levels consistent with the AAP statement that phototherapy can be offered below the AAP treatment threshold per the provider’s discretion.
• Additional criteria for inpatient phototherapy for hyperbilirubinemia, to be used in conjunction with this policy, can be found in clinical decision support tools.

III. It is the policy of Centene Corporation that other treatment for hyperbilirubinemia, including inpatient phototherapy (when not meeting criteria for home phototherapy per this policy) and exchange transfusion, is medically necessary when meeting the most current version of the relevant nationally recognized decision support tools.

Clinical Policy

Phototherapy for Neonatal Hyperbilirubinemia

Background

Efforts to reduce kernicterus include prevention and management of hyperbilirubinemia. Preventive strategies focus on identifying at-risk infants and beginning preventive therapeutic interventions as needed, which may be performed by universal screening of all neonates for hyperbilirubinemia, usually through measurement of total serum bilirubin (TSB) or by use of a transcutaneous device to obtain a Transcutaneous bilirubin (TcB) level.²

G6PD deficiency is now recognized as one of the most significant causes of hyperbilirubinemia leading to kernicterus. Identifying neonates with G6PD deficiency is challenging, so knowledge of certain risk factors for this deficiency can lead to improved health outcomes. G6PD deficiency is more common in males because it is a sex-linked recessive gene located on the X chromosome, and males only have one X chromosome. G6PD deficiency is prevalent in populations with genetic ancestry from Sub-Saharan Africa, Middle East, Mediterranean, Arabian Peninsula, and Southeast Asia. Additionally, 13% of African American males and 4% of African American females have G6PD deficiency.³

Phototherapy is considered first-line treatment for neonatal hyperbilirubinemia, defined as TSB > 95th percentile on the hour-specific Bhutani nomogram for infants ≥ 35 weeks gestational age (GA).¹ Phototherapy has been used widely for over 60 years and has been associated with few adverse events in term infants. Phototherapy decreases or reduces the rate of rise of bilirubinemia in almost all cases, regardless of the cause.² It also reduces the risk that TSB will reach the level associated with increased risk of kernicterus and that at which exchange transfusion is recommended.

Some infants are more likely to be readmitted for treatment of hyperbilirubinemia after discharge from their birth hospitalization. Infants discharged in the first two days after birth were more likely to be readmitted for jaundice compared with infants who stayed longer than three days, an association that decreased with increasing GA.⁴ Other risk factors for hyperbilirubinemia include vaginal delivery, exclusively breastfeeding at discharge, primiparous mother, maternal age less than 20 years old, mother with an Asian country of birth, and higher TSB relative to the treatment threshold at phototherapy initiation.⁴,⁵

Phototherapy works by using photons from light to alter bilirubin molecules in the superficial capillaries into water-soluble, non-neurotoxic molecules and reducing unconjugated TB levels.¹ Conventional phototherapy is delivered by irradiance in the blue-green spectrum (wavelengths of approximately 460 to 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 is delivered to as much of the infant’s surface area as possible.¹,⁶ Conventional phototherapy may be delivered in the hospital or in the home setting.⁷

Home phototherapy can be less disruptive to the family and is appropriate for otherwise healthy, term infants without hemolysis and other risk factors, who have TB levels 2 to 3 mg/dL below the recommended threshold level for initiation of hospital phototherapy, are feeding well, and can be closely followed.¹ Per the updated 2022 clinical practice guidelines from the American Academy of Pediatrics (AAP), home phototherapy is an option that can be started at a lower

Clinical Policy

Phototherapy for Neonatal Hyperbilirubinemia

threshold, such as 2 mg/dL below the phototherapy threshold, to reduce the risk of hospital readmission.³ During phototherapy, infants should be placed on their backs and fully exposed to the light with the exception of a diaper. Their eyes should be shielded with an opaque blindfold with attention given to prevent the blindfold from covering the nose or sliding off the eyes.¹

American Academy of Pediatrics (AAP)

In 2022 the AAP published updated clinical practice guidelines that are meant to replace the 2004 clinical guidelines concerning the assessment and treatment of neonatal hyperbilirubinemia in infants ≥35 weeks.³ The 2022 AAP guidelines focus on recommendations for when infants should have a direct antiglobulin test (DAT) and blood type testing; implementation of care practices that promote evidence-based breastfeeding support that is family-centered; recommendation against providing the infant with water or dextrose water as an oral supplementation to prevent hyperbilirubinemia or to decrease bilirubin levels; importance of assessing for glucose-6-phosphate dehydrogenase (G6PD) deficiency; assessment for hyperbilirubinemia neurotoxicity risk factors; recommendations for when total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) should be measured; recommendations for phototherapy treatment. The 2022 AAP guidelines address the issues of prevention, risk assessment, monitoring, and treatment of neonatal hyperbilirubinemia in infants ≥ 35 weeks.³

National Institute for Health and Care Excellence (NICE)

NICE guidelines cover diagnosing and treating jaundice in order to detect and prevent very high levels of bilirubin. They provide consensus-based thresholds for when phototherapy and exchange transfusion should be initiated by age in hours.⁸

United States Preventive Services Task Force (USPSTF)

The USPSTF stated there was insufficient evidence to make recommendations regarding screening for hyperbilirubinemia for infants ≥ 35 weeks. They note that risk factors for hyperbilirubinemia include family history of neonatal jaundice, exclusive breastfeeding, bruising, cephalohematoma, ethnicity (Asian or black), maternal age older than 25 years, male sex, glucose-6-phosphate dehydrogenase deficiency, and gestational age less than 38 weeks. The specific contribution of these risk factors to chronic bilirubin encephalopathy in healthy children is not well understood. Currently, the USPSTF notes this recommendation is “inactive.”⁹

Coding Implications

This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2023, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

Clinical Policy

Phototherapy for Neonatal Hyperbilirubinemia

Clinical Policy

Phototherapy for Neonatal Hyperbilirubinemia

Clinical Policy

Phototherapy for Neonatal Hyperbilirubinemia

Important Reminder

This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions, and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

Clinical Policy

Phototherapy for Neonatal Hyperbilirubinemia

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

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