DESCRIPTION
Home phototherapy for neonatal jaundice involves the continuous application of ultraviolet light via a lamp or fiber optic system to the infant in the home for a prescribed period of time. Phototherapy is intended to reduce elevated bilirubin levels that could cause brain damage in the infant.
POLICY
Home phototherapy for neonatal jaundice is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Home phototherapy for the treatment of other conditions / diseases is considered investigational.
MEDICAL APPROPRIATENESS
Home phototherapy for a term infant with neonatal jaundice is considered medically appropriate if ALL of the following criteria are met:
Elevated bilirubin not due to any primary hepatic disorder
Hospitalization is no longer required
Diagnostic evaluation is performed prior to the therapy and should include ALL of the following:
History and physical examination
Hemoglobin concentration or hematocrit
WBC count and differential count
Blood smear for red cell morphology platelets
Reticulocyte count
Total and direct-reacting bilirubin concentration
Maternal and infant blood typing and Coombs test
Urinalysis including a test for reducing substances
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
American Academy of Pediatric guidelines for phototherapy to manage hyperbilirubinemia in the healthy term newborn are as follows:
|
Age in hours |
Consider Phototherapy |
Recommend Phototherapy |
|
Total Serum Bilirubin level mg/dL |
||
|
24 or less |
if rapidly rising |
**** |
|
25 to 48 |
greater than 12 |
greater than 15 |
|
49-72 |
greater than 15 |
greater than 18 |
|
greater than 72 |
greater than 17 |
greater than 20 |
Conditions that significantly increase the risk of hyperbilirubinemia include, but are not limited to, any of the following, history of previous sibling with hyperbilirubinemia, decreasing gestational age, breast feeding, and large weight loss after birth.
Scientific evidence is lacking in the form of well-designed studies in peer-reviewed journals regarding the utilization of home phototherapy for other conditions or diseases.
SOURCES
Agency for Healthcare Research and Quality. (2002 November). Management of neonatal hyperbilirubinemia summary. Retrieved August 28, 2009 from http://www.ahrq.gov.
American Academy of Pediatrics. Practice Guidelines. (1994, October). Management of hyperbilirubinemia in the healthy term newborn (Vol. 94, No. 4). Retrieved August 28, 2009 from http://aappolicy.aappublications.org/cgi/reprint/pediatrics;94/4/558.pdf.
Atkinson, L. R., Escobar, G. J., Takayama, J. I., & Newman, T. B. (2003). Phototherapy use in jaundiced newborns in a large managed care organization: Do clinicians adhere to the guideline? Pediatrics, 111 (5, Pt. 1), e555-e561. (Level 4 Evidence)
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2004l). Home phototherapy for neonatal jaundice (1.01.07). Retrieved September 2, 2009 from BlueWeb.
Kliegman, R. M., Behrman, R. E., Jenson, H. B. & Stanton, B. (Eds.). (2007). Nelson Textbook of Pediatrics (18th ed., pp. 756 - 765). Philadelphia: Saunders Elsevier Company.
Kuzniewicz, M., Escobar, G., Wi, S., Liljestrand, P., McCulloch, C., & Newman, T. (2008). Risk factors for severe hyperbilirubinemia among infants with borderline bilirubin levels: a nested case-control study. Journal of Pediatrics, 153 (2), 234 - 240. (Level 4 Evidence)
Maisels, M., & McDonagh, A. (2008). Phototherapy for neonatal jaundice. New England Journal of Medicine, 358 (9) 920 - 928. (Level 5 Evidence, Industry sponsored)
Mills JF, Tudehope D. Fibreoptic phototherapy for neonatal jaundice. The Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD002060. DOI: 10.1002/14651858.CD002060.
Moerschel, S., Cianciaruso, L., & Tracy, L. (2008). A practical approach to neonatal jaundice. American Family Physician, 77 (9), 1255 - 1262. (Level 5 Evidence)
National Guideline Clearinghouse. National Center for Primary Care. (2008 January). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Retrieved September 2, 2009 from http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5419&nbr=3716.
Tennessee Code: Title 68: Health, Safety and Environmental Protection: Chapter 11: Part 2 Regulation of Health and Related Facilities: Definitions. 68-11-201. Retrieved August 28, 2009 from http://www.michie.com/tennessee/lpext.dll?f=templates&fn=main-h.htm&cp=tncode.
U. S. Food and Drug Administration. (2006, April). Center for Devices and Radiological Health. 510 (k) Premarket Notification Database. K053568. Retrieved August 28, 2009 from. http://www.accessdata.fda.gov/cdrh_docs/pdf5/K053568.pdf.
U. S. Food and Drug Administration. (2007, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K0718280, Retrieved August 28, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf7/K071828.pdf.
U. S. Food and Drug Administration. (2007, October). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K072097, Retrieved August 28, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf7/K072097.pdf.
U. S. Food and Drug Administration. (2007, October). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K0718280, Retrieved August 28, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf8/K083179.pdf.
Watchko, J. (2009). Identification of neonates as high risk for hazardous hyperbilirubinemia: emerging clinical Insights. Pediatric Clinics of North America, 56 (3), 671 - 678. (Level 5 Evidence)
ORIGINAL EFFECTIVE DATE: 11/1986
MOST RECENT REVIEW DATE: 10/8/2009
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.