CurrentCentenePolicy CPMP.150

Phototherapy for Neonatal Hyperbilirubinemia

Defines medical necessity criteria for conventional (LED-based) home phototherapy for infants (>=38 weeks gestation) with physiologic neonatal hyperbilirubinemia, describes when inpatient phototherapy/exchange transfusion are medically necessary, and provides coding implications.

Policy Summary

PayerCentene

PolicyPhototherapy for Neonatal Hyperbilirubinemia

Policy CodePolicy CPMP.150

Change TypeCriteria revisions and clarifications

Effective Date

Next Review Date

Key ActionEnsure daily total serum bilirubin (TSB) measurement during home phototherapy and document absence of listed risk factors and a PCP-managed follow-up plan within 12–24 hours.

POLICY UPDATE CHANGES

Updated home phototherapy criteria to require infant >= 48 hours old, LED device availability, no prior phototherapy, and daily TSB measurement (prior revisions over 2017-2024).

Added note that infants should be admitted for inpatient phototherapy if TSB is >1 mg/dL above AAP threshold per bili risk tool.

Updated Criteria I.J.1. wording from 'glucose-6-phosphate dehydrogenase (G6PD)' to 'G6PD deficiency' (06/25 revision).

ICD-10 codes were removed from the policy (historical change).

17Listed risk factors that exclude home phototherapy

5TSB age-threshold rows in Table 1

Referenced procedure codes

Coverage Summary

Policy CPMP.150: Conventional LED-based home phototherapy is covered with criteria for otherwise healthy infants (>= 38 weeks gestation) with physiologic neonatal hyperbilirubinemia when all home phototherapy criteria are met (see policy for full list). The policy specifies requirements including infant clinical stability, availability of an LED device in the home, no prior phototherapy, infant >= 48 hours old, daily TSB measurement, provider willingness to manage home care with follow-up within 12–24 hours, and absence of listed risk factors. Inpatient phototherapy and exchange transfusion are medically necessary when home criteria are not met or extenuating circumstances exist, and infants should be admitted if TSB is > 1 mg/dL above the AAP phototherapy treatment threshold per the AAP bili risk tool. Status: CURRENT.

Key thresholds and scope

Gestational-age scopeInfants >= 38 weeks gestation

TSB home thresholds by age (Table 1)24–36 h: <13 mg/dL; 36–48 h: <14 mg/dL; 48–60 h: <15 mg/dL; 60–72 h: <16 mg/dL; >=72 h: <17 mg/dL

Inpatient admission threshold vs AAPAdmit if TSB > 1 mg/dL above AAP phototherapy treatment threshold per AAP bili risk tool

Preferred phototherapy irradianceIntensive phototherapy: >=30 µW/cm2/nm in blue‑green spectrum (~460–490 nm) measured at infant skin

Home phototherapy eligible offset per AAP 2022Home phototherapy may be offered at lower thresholds (e.g., ~2 mg/dL below AAP threshold) to reduce readmission, per AAP 2022 guidance and policy note

Referenced guidelineAmerican Academy of Pediatrics clinical practice guideline, 2022 (AAP bili risk tool)

Medical Necessity Criteria

Home phototherapy — Medically necessary criteria

Home conventional phototherapy (single light source, blue-green spectrum 460–490 nm) is medically necessary when ALL of the following are met:

ALL of the following

Infant status is one of the following:
- Previously discharged home and readmission is being considered only for hyperbilirubinemia
- Infant is currently inpatient and ready for discharge except for needing treatment for elevated bilirubin
Infant is >= 38 weeks gestation
Infant is feeding well, is active, and clinically well

Provider Actions & Billing Guidance

Documentation Required

Daily TSB measurement

Total serum bilirubin must be measured daily during home phototherapy.

Documentation Required

Risk factor assessment and documentation

Document absence of listed risk factors (hemolysis, G6PD deficiency, HIE, sepsis, instability, conjugated bilirubin elevation, early jaundice, etc.) prior to approving home phototherapy.

Coding

Covered/Referenced CPT/HCPCS codes for phototherapy and home visit servicesCPT|HCPCSCovered

E0202	Phototherapy (bilirubin) light with photometer
S9098	Home visit, phototherapy services (Bili-lite), including equipment rental, nursing services, blood draw supplies and other services, per diem

Background, Evidence & Definitions

Phototherapy is the first-line treatment for unconjugated neonatal hyperbilirubinemia and reduces the risk of kernicterus by lowering or slowing the rise of total serum bilirubin (TSB). Intensive phototherapy is preferred using the blue-green spectrum (~460–490 nm) with irradiance >= 30 µW/cm2/nm measured at the infant’s skin. Per AAP 2022 guidance, home phototherapy can be appropriate for otherwise healthy term infants without hemolysis or other listed risk factors whose TSB levels are approximately 2–3 mg/dL below inpatient treatment thresholds; the AAP bili risk calculator can be used to set treatment/admission thresholds and the policy notes infants should be admitted if TSB is > 1 mg/dL above the AAP phototherapy threshold. The AAP 2022 guideline also informs assessment of risk factors, monitoring, and when TSB or TcB should be measured.

Evidence

Unsupported block type: paragraph

Unsupported block type: items

Revision History

06/25revisedLatest

Updated Criteria I.J.1. wording from 'glucose-6-phosphate dehydrogenase (G6PD)' to 'G6PD deficiency' (06/25 revision); coding and descriptions reviewed; background updated with no impact to clinical criteria.

2017-2024 (multiple prior revisions)revised (material)

Updated home phototherapy criteria to require infant >= 48 hours old, LED device availability, no prior phototherapy, and daily TSB measurement; multiple criteria (I.D., I.F., I.G., I.H.) and measurement frequency clarified and risk factors list expanded (material change).

10/22clarified (material)

Policy Summary

PayerCentene

PolicyPhototherapy for Neonatal Hyperbilirubinemia

Policy CodePolicy CPMP.150

Change TypeCriteria revisions and clarifications

Effective Date

Next Review Date

Key ActionEnsure daily total serum bilirubin (TSB) measurement during home phototherapy and document absence of listed risk factors and a PCP-managed follow-up plan within 12–24 hours.

On This Page

Lactation support from a qualified professional has been offered (for breastfeeding/chestfeeding)

Primary care provider is willing to manage home care with established follow-up within 12 to 24 hours after discharge

Infant is >= 48 hours old

No previous phototherapy

An LED-based phototherapy device will be available in the home without delay

Total serum bilirubin (TSB) will be measured daily

Infant has none of the listed risk factors

Isoimmune hemolytic disease (e.g., positive direct antiglobulin test), G6PD deficiency, or other hemolytic disease
Hypoxic ischemic encephalopathy (HIE)/asphyxia
Sepsis
Temperature instability
Acidosis
Albumin < 3.0 g/dL (if measured)
Birth weight < 2500 g
Significant cephalohematoma or bruising
Weight loss >= 10%
Elevated direct-reacting/conjugated bilirubin
Jaundice appearing in first 24 hours of life
Laboratory or clinical evidence of hypothyroidism
Significant clinical instability in the previous 24 hours
Clinical history of a parent or sibling requiring phototherapy or exchange transfusion
Exclusive breastfeeding or chestfeeding with suboptimal intake
Down syndrome
Macrosomic infant of a diabetic mother

TSB age-thresholds

Age 24 to 36 hours: TSB < 13 mg/dL
Age 36 to 48 hours: TSB < 14 mg/dL
Age 48 to 60 hours: TSB < 15 mg/dL
Age 60 to 72 hours: TSB < 16 mg/dL
Age >= 72 hours: TSB < 17 mg/dL

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Inpatient phototherapy / Exchange transfusion — Medically necessary criteria

Inpatient phototherapy and exchange transfusion are medically necessary when meeting nationally recognized decision support tools (e.g., AAP bili risk calculator) and when not meeting home phototherapy criteria or when extenuating circumstances exist:

ANY of the following

Documentation supports that criteria for home phototherapy are not met
Extenuating circumstances including expected lack of ability to adhere to therapy at home
Infant should be admitted for inpatient phototherapy if TSB concentration is > 1 mg/dL above the AAP guidelines phototherapy treatment threshold per the AAP bili risk tool

Prior Authorization

Home phototherapy requires provider management and follow-up plan

Primary care provider must be willing to manage home care with established follow-up within 12 to 24 hours after discharge and document that lactation support was offered; ensure an LED-based phototherapy device will be available in the home without delay.

Billing Rule

Use referenced phototherapy codes

Report E0202 for phototherapy light with photometer and S9098 for home phototherapy visit/equipment rental per diem as applicable.

E0202
S9098

Denial Risk

Inpatient required if thresholds/risk factors exceed policy

Claims for home phototherapy may be denied if the infant does not meet ALL home phototherapy criteria, or if the TSB concentration is >1 mg/dL above the AAP phototherapy treatment threshold without documentation of extenuating circumstances (including lack of expected compliance with therapy at home).

Added note that infants should be admitted for inpatient phototherapy if TSB is >1 mg/dL above AAP threshold per the AAP bili risk tool and clarified that Table 1 values are conservative and AAP tool thresholds govern admission decisions.

various (prior revisions)removed

ICD-10 codes were removed from the policy during prior revisions; coding references remain in CPT/HCPCS (historical change).