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.

Clinical Indications

Medically Necessary:

Home phototherapy devices are considered medically necessary when the criteria below are met:

1. The infant has neonatal hyperbilirubinemia; and
2. Is ready to be discharged from the hospital or is already discharged; and
3. Has no known hyperbilirubinemia neurotoxicity risk factors; and
4. Total serum bilirubin concentration is no more than 1 mg/dL above the phototherapy treatment threshold as defined by the American Academy of Pediatrics Clinical Practice Guideline*; and
5. Phototherapy equipment used in the home, such as a fiberoptic blanket or band, is provided by a durable medical equipment (DME) provider.

*American Academy of Pediatrics Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation is available at: https://publications.aap.org/pediatrics/article/150/3/e2022058859/188726/Clinical-Practice-Guideline-Revision-Management-of?searchresult=1)

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.