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ModifiedCurativePolicy CHP-IP-2026-090

Bronchopulmonary Dysplasia

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Medical necessity for continued NICU or special care nursery stays, level of care, discharge readiness, and readmission for respiratory decompensation in neonates and young infants with evolving or established bronchopulmonary dysplasia.

Policy Summary

PayerCurative

PolicyBronchopulmonary Dysplasia

Policy CodePolicy CHP-IP-2026-090

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument respiratory support mode and flow at 36 weeks PMA and the resulting BPD grade.

SourceLink

POLICY UPDATE CHANGES

The policy replaces the former oxygen-based BPD severity scheme with the Jensen 2019 respiratory-support grades at 36 weeks postmenstrual age.

BPD is changed from an admission diagnosis to criteria focused on continued stay and discharge readiness.

The policy adds pathways for BPD-associated pulmonary hypertension and tracheostomy with chronic home ventilation.

Stable low-flow oxygen alone does not justify continued inpatient care when discharge readiness criteria are met and home oxygen is arranged.

3Jensen BPD grades

ALL 10Discharge criteria

24–72 hoursConcurrent review

5–7 daysEvent-free observation

0.20FiO2 red flag

Medical Necessity and Level-of-Care Criteria

Inpatient admission

Covered when BOTH a clinical severity finding and a hospital-level service are present.

Clinical severity finding
- Preterm infant with support: Born below 32 weeks and requiring positive-pressure respiratory support or supplemental oxygen at 28 days of age or older, or at 36 weeks PMABPD grade 1 to 3
- Grade 2 or 3 support: High-flow nasal cannula above 2 L/min, noninvasive positive pressure, or invasive ventilation
- Acute decompensation: Rising FiO2, hypercapnia with respiratory acidosis, or increased work of breathing requiring escalation of support

Policy Summary

PayerCurative

PolicyBronchopulmonary Dysplasia

Policy CodePolicy CHP-IP-2026-090

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument respiratory support mode and flow at 36 weeks PMA and the resulting BPD grade.

SourceLink

On This Page

FiO2 increase of 0.20 or more

Pulmonary hypertension: BPD-associated pulmonary hypertension documented on echocardiography

Hospital-level service

Positive-pressure support: CPAP, noninvasive ventilation, high-flow nasal cannula, or invasive ventilation
Oxygen titration: Supplemental oxygen requiring frequent titration to the target saturation range
Systemic corticosteroid course: Low-dose dexamethasone or hydrocortisone after shared decision-making with parents
Pulmonary vasodilator management: Pulmonary vasodilator initiation or titration with echocardiographic monitoring
Tracheostomy and chronic ventilation: Tracheostomy placement and initiation of chronic home ventilation with caregiver training

Observation or outpatient instead of inpatient

Discharge home is appropriate when the infant has stable grade 1 BPD, consistent saturations, home oxygen arranged, and trained caregivers.

Stable grade 1 discharge: Stable grade 1 BPD on low-flow oxygen with consistent saturations, arranged home oxygen, and trained caregivers

Outpatient pulmonology follow-up is required.

Level of care: intensive care unit

NICU AAP Level III or IV intensive care is appropriate when ANY criterion is present.

Intensive-care level

Initial intensive phase: Gestational age below 32 0/7 weeks or birth weight below 1500 g during initial stabilization and intensive phase
AAP Level III population.
Advanced respiratory support: Invasive mechanical ventilation beyond brief stabilization, high-frequency ventilation, or inhaled nitric oxide
Hemodynamic support: Vasoactive or inotropic infusion, or volume resuscitation for hypotension or poor perfusion
Critical procedures or monitoring: Therapeutic hypothermia, ECMO, exchange transfusion, or continuous arterial blood pressure monitoring through an umbilical or peripheral arterial line
On-site surgical or cardiac care: Surgical or interventional condition requiring pediatric surgical or cardiac subspecialty care on site, including preoperative and postoperative periods
AAP Level IV.
Severe BPD or crisis: Grade 3 BPD on invasive ventilation or BPD with pulmonary hypertensive crisis

Level of care: step-down or intermediate care

Special care nursery AAP Level II or NICU intermediate/continuing care is appropriate when intensive-care criteria are not met and ANY criterion is present.

Intermediate-care level

Physiologic immaturity or moderate illness: Gestational age 32 0/7 weeks or more and birth weight 1500 g or more with apnea of prematurity, inability to maintain temperature, inability to take all feeds orally, or moderate illness expected to resolve rapidly
AAP Level II.
Noninvasive or brief ventilatory support: Nasal CPAP, high-flow nasal cannula, or mechanical ventilation of brief duration while stabilizing or awaiting transferMechanical ventilation under 24 hours
Basic nutritional support: Gavage feeding, intravenous fluids, or parenteral nutrition through peripheral access in an otherwise stable infant
Convalescent care: Back-transfer from a Level III or IV unit for growth, feeding, and event monitoring
BPD weaning or low-flow oxygen: Grade 1 or 2 BPD weaning from noninvasive support or on low-flow oxygen with ongoing titration while growing and feeding

Level of care: medical-surgical unit

Medical-surgical equivalent care is appropriate when ANY criterion applies and no intensive or intermediate criterion is met.

Medical-surgical or Level I care

Stable term or late-preterm infant: Gestational age 35 0/7 weeks or more, normal temperature in an open crib, breathing room air, and feeding orally
AAP Level I well newborn or mother-baby care.
Other low-acuity need: Routine observation after reassuring sepsis risk assessment or phototherapy below exchange thresholds in a well infant

Discharge readiness

Discharge is appropriate when ALL criteria are met. Items not applicable to a term infant with a short stay may be documented as not applicable.

Thermoregulation: Normal axillary temperature maintained in an open crib in room-temperature clothing and bedding36.5 to 37.5 C
Feeding: All feeds taken by breast or bottle without cardiorespiratory compromise, or an established tube-feeding plan with equipment arranged and caregivers trained and competent
Growth: Sustained weight gain documented over several consecutive daysAbout 20 to 30 g/day may guide assessment but is not a hard threshold; no minimum discharge weight
Respiratory control: No clinically significant apnea, bradycardia, or desaturation during the required event-free observation periodCommonly 5 to 7 days after caffeine is stopped
Longer observation may be needed for the lowest gestational ages.
Respiratory status: Room air, or stable low-flow home oxygen with target saturations met, home equipment delivered, and caregivers trained
Screening and immunization: Newborn metabolic screen, hearing screen, critical congenital heart disease screen when not otherwise evaluated by echocardiography, eligible retinopathy examinations, and age-appropriate immunizations completed or scheduled
Car safety seat observation completed for infants born before 37 weeks or with hypotonia or airway risk
Use an appropriate car seat or car bed.
Caregiver and follow-up readiness: Caregiver competency documented for feeding, medications, equipment, safe sleep, infant CPR, and warning signs; primary care visit scheduled within a few days and indicated subspecialty and early-intervention referrals made
Stable respiratory support and follow-up: Stable on room air or fixed low-flow oxygen for several days without desaturation during feeds or sleep; home equipment delivered; pulmonology follow-up arranged and cardiology follow-up arranged when pulmonary hypertension is present
Tracheostomy and home ventilation readiness: For infants with tracheostomy and home ventilation, two trained caregivers, a home nursing plan, equipment, and an emergency plan are in place

Continued-stay criteria

Continued stay is medically necessary when discharge readiness has not been met and ANY qualifying condition is documented.

Respiratory support: Any positive-pressure support, or oxygen requiring frequent titration or not yet stable at a home-oxygen requirement
Apnea, bradycardia, or desaturation: Clinically significant events within the current event-free window, or ongoing caffeine therapy with events
Temperature instability: Unable to maintain normal temperature in an open crib
Feeding or fluid support: Not taking all feeds orally with adequate intake, or parenteral nutrition or intravenous fluids remain necessary when discharge with tube feeding is not feasible
Medication requiring inpatient care: Intravenous antimicrobial, anticonvulsant, vasoactive, or other medication cannot safely be given at home
Procedure or complication: Pending or recent surgery or procedure, or newly identified complication under active evaluation
Grade 2 or 3 BPD support: Grade 2 or 3 BPD remains on positive-pressure support
Pulmonary hypertension treatment: Pulmonary hypertension therapy is being initiated or titrated
Tracheostomy training: Home-ventilation caregiver training is not complete

High-dose dexamethasone at 0.5 mg/kg/day or more for chronic lung disease is not recommended and does not meet the coverage criteria under this policy.

A continued inpatient stay does not meet criteria when it is solely for stable low-flow oxygen, to reach a target weight or postmenstrual age, to complete testing that can occur the same day or as an outpatient, or because of social, placement, transportation, or caregiver-availability barriers. Observation of a well-appearing infant at 35 weeks or more without a clinical severity finding is also excluded.

A stable low-flow oxygen requirement alone is not medically necessary for continued inpatient care when all other discharge-readiness criteria are met and home oxygen has been arranged. Home oxygen is an appropriate alternative, with outpatient follow-up and discharge planning.

High-dose dexamethasone at 0.5 mg/kg/day or more for chronic lung disease is not medically necessary under this policy. Requests involving this dose require physician review.

Continued hospitalization solely to reach a target weight or specific postmenstrual age is not medically necessary when the infant has met physiologic discharge criteria. Discharge decisions are based on physiologic competencies rather than a fixed weight or age target.

A separate inpatient day solely to await a car-seat observation, hearing screen, or other test that can be completed the same day or arranged as an outpatient is not medically necessary. The test should be completed before discharge when feasible or scheduled outpatient.

Days continued solely for social, placement, transportation, or caregiver-availability reasons after the infant is medically ready for discharge are not medically necessary. These circumstances are routed to physician review and discharge planning; days already authorized are not retroactively denied.

Admission to a NICU or special care nursery solely to observe a well-appearing infant born at 35 weeks or more, without a clinical severity finding, is not medically necessary. Level I well-newborn or mother-baby care is appropriate.

Diagnostic, Procedural, and Operational Coding

ICD-10-CM: chronic perinatal lung diseaseICD-10

P27.1	Chronic perinatal lung disease
P27.0	Chronic perinatal lung disease
P27.8	Chronic perinatal lung disease
P27.9	Chronic perinatal lung disease
J84.841	Chronic perinatal lung disease

ICD-10-CM: added pulmonary hypertension due to lung diseaseICD-10

I27.23

Pulmonary hypertension due to lung disease

ICD-10-PCS: ventilation and tracheostomyICD-10

5A09557	Ventilation and tracheostomy
5A0955A	Ventilation and tracheostomy
5A1955Z	Ventilation and tracheostomy
0B110F4	Ventilation and tracheostomy
0B113F4	Ventilation and tracheostomy

MS-DRG (FY2027 v44)Revenue

003	MS-DRG
790	MS-DRG
791	MS-DRG
792	MS-DRG

Revenue codesRevenue

0173	Revenue code
0174	Revenue code
0410	Revenue code
0250	Revenue code
0300	Revenue code

ICD-10-CM: chronic perinatal lung disease (v4.0)ICD-10

P27.1	chronic perinatal lung disease (v4.0)
P27.0	chronic perinatal lung disease (v4.0)
P27.8	chronic perinatal lung disease (v4.0)
P27.9	chronic perinatal lung disease (v4.0)
J84.841	chronic perinatal lung disease (v4.0)

ICD-10-CM: added pulmonary hypertension due to lung diseaseICD-10

I27.23

added pulmonary hypertension due to lung disease

ICD-10-PCS: ventilation and tracheostomyICD-10

5A09557	ventilation and tracheostomy
5A0955A	ventilation and tracheostomy
5A1955Z	ventilation and tracheostomy
0B110F4	ventilation and tracheostomy
0B113F4	ventilation and tracheostomy

MS-DRG (FY2027 v44)mixed

003	MS-DRG (FY2027 v44)
790	MS-DRG (FY2027 v44)
791	MS-DRG (FY2027 v44)
792	MS-DRG (FY2027 v44)

Revenue codesRevenue

0173	Revenue codes
0174	Revenue codes
0410	Revenue codes
0250	Revenue codes
0300	Revenue codes

FiO2 increase

ThresholdAn increase in FiO2 of 0.20 or more.

Clinical significanceA rising FiO2 at this level is an acute respiratory decompensation finding.

Required responseImmediate bedside neonatologist evaluation and escalation of respiratory support are required; transfer to Level III or IV care if needed.

BPD grade 1 respiratory support

BPD classificationGrade 1 BPD.

Respiratory supportNasal cannula at 2 L/min or less at 36 weeks PMA.

Related classificationNo BPD means no respiratory support at 36 weeks PMA.

BPD grade 2 respiratory support

BPD classificationGrade 2 BPD.

Respiratory supportNasal cannula above 2 L/min at 36 weeks PMA, or noninvasive positive airway pressure.

Alternative supportGrade 2 also includes high-flow nasal cannula above 2 L/min or noninvasive positive pressure.

BPD grade 3 respiratory support

BPD classificationGrade 3 BPD.

Respiratory supportInvasive mechanical ventilation at 36 weeks PMA.

Severity contextGrade 3 BPD on invasive ventilation is an intensive-care criterion.

High-dose dexamethasone

Dose thresholdDexamethasone at 0.5 mg/kg/day or more.

Policy positionHigh-dose dexamethasone for chronic lung disease is not recommended under this policy.

Review pathwayRequests for high-dose dexamethasone are referred for physician review.

Discharge temperature

Temperature range36.5 to 37.5 C axillary temperature.

Care settingThe temperature must be maintained in an open crib with room-temperature clothing and bedding.

Discharge requirementNormal temperature maintained in an open crib is required for discharge readiness.

Event-free observation

Usual observation periodCommonly 5 to 7 days after caffeine is stopped.

Extended observationLonger observation may be needed for infants born at the lowest gestational ages.

Discharge standardNo clinically significant apnea, bradycardia, or desaturation may occur during the required event-free period.

Brief mechanical ventilation

Duration thresholdMechanical ventilation under 24 hours.

Care contextBrief mechanical ventilation may occur while the infant is stabilizing or awaiting transfer.

Level-of-care pathwayNasal CPAP, high-flow nasal cannula, or brief mechanical ventilation may support intermediate care when intensive-care criteria are not met.

NICU intensive-care population

Gestational-age criterionGestational age below 32 0/7 weeks.

Birth-weight criterionBirth weight below 1500 g.

Applicable phaseThese criteria apply during initial stabilization and the intensive phase and identify an AAP Level III population.

Level I physiologic stability

Gestational ageAt least 35 0/7 weeks.

Physiologic requirementsNormal temperature in an open crib, breathing room air, and feeding orally.

Care levelThis profile supports AAP Level I well-newborn or mother-baby care when no intensive or intermediate criterion is met.

BPD severity assessment

Assessment measureRespiratory support mode.

Assessment timeAt 36 weeks postmenstrual age.

Classification basisThe Jensen definition grades BPD by respiratory-support mode rather than oxygen exposure alone, regardless of supplemental oxygen use.

Authorization and Documentation Requirements

Prior Authorization

Initial Inpatient Medical Necessity

Approve inpatient NICU or special care nursery care for BPD when both conditions are met: at least one clinical severity finding and at least one required hospital-level service.

Clinical severity findings include qualifying prematurity with ongoing respiratory support or oxygen, grade 2 or 3 BPD requiring high-flow nasal cannula above 2 L/min, noninvasive positive pressure, or invasive ventilation; acute decompensation; or BPD-associated pulmonary hypertension on echocardiography.
Hospital-level services include positive-pressure respiratory support, oxygen requiring frequent titration, a low-dose systemic corticosteroid course after parental shared decision-making, pulmonary vasodilator initiation or titration with echocardiographic monitoring, or tracheostomy with initiation of chronic home ventilation and caregiver training.

Documentation Required

Concurrent Continued-Stay Review

For each continued-stay period, document that discharge readiness has not been met and that at least one qualifying continued-stay condition remains present. Perform concurrent review every 24 to 72 hours during the intensive phase and at least every 7 days during stable convalescent growth, with daily attending documentation.

Qualifying conditions include ongoing positive-pressure support or oxygen requiring frequent titration; significant apnea, bradycardia, or desaturation or ongoing caffeine with events; inability to maintain temperature in an open crib; inadequate oral feeding or ongoing parenteral nutrition or IV fluids when tube-feeding discharge is not feasible; unsafe-to-administer-at-home medications; pending surgery, a newly identified complication, grade 2 or 3 BPD on positive pressure, pulmonary hypertension under treatment titration, or incomplete tracheostomy home-ventilation training.

Documentation Required

Document Growth and Maturity

Submit the infant’s growth and maturity data for review.

Gestational age in completed weeks and days
Birth weight
Current postmenstrual age (PMA)
Current weight

Documentation Required

Document Respiratory Support

Document the infant’s daily respiratory support and oxygenation targets.

Respiratory support mode and settings
FiO2
Target saturation range

Documentation Required

Document Feeding Status

Document feeding progress and ongoing nutritional support.

Feeding route
Volume in mL/kg/day
Percentage taken orally
Parenteral nutrition status

Documentation Required

Document Thermoregulation

Document the support required for thermoregulation.

Indicate whether the infant is in an incubator, under a radiant warmer, or in an open crib.

Documentation Required

Document Event History

Provide the current event history and caffeine plan.

Apnea, bradycardia, and desaturation event log
Interventions required for each event
Caffeine stop date

Documentation Required

Document Clinical Treatment

Document treatment details relevant to the medical-necessity criteria.

Medications
Vascular access devices
Relevant laboratory results
Relevant imaging results

Documentation Required

Document Level-of-Care Rationale

Document the treating unit’s AAP level and why that level of care is required for the infant.

AAP level of the treating unit
Clinical rationale for requiring that level

Documentation Required

Document Discharge Planning

Provide the discharge-readiness and transition-of-care record.

Discharge readiness checklist
Screening results
Caregiver training
Home equipment
Follow-up appointments

Documentation Required

Document BPD Grade

At 36 weeks PMA, document the respiratory support mode and flow and the resulting BPD grade.

Respiratory support mode at 36 weeks PMA
Flow at 36 weeks PMA
Resulting BPD grade

Documentation Required

Document Pulmonary Hypertension Evaluation

Document applicable echocardiographic screening for BPD-associated pulmonary hypertension.

Include the echocardiogram result when pulmonary hypertension is suspected, being evaluated, or under treatment.

Documentation Required

Document Corticosteroid Treatment

For systemic corticosteroid treatment, document the complete course and shared decision-making with the parents.

Corticosteroid name and course
Dose
Parental discussion or shared decision-making

Documentation Required

Document Home Ventilation Readiness

When applicable, document tracheostomy and readiness for chronic home ventilation.

Tracheostomy records
Home-ventilation training records
Caregiver training completion status

Unsupported block type: denial_riskใ},{

Denial Risk

High-Dose Dexamethasone Requires Physician Review

High-dose dexamethasone at 0.5 mg/kg/day or more does not meet criteria under this policy and requires physician review.

The request is not automatically denied; refer it for review by a licensed physician of the same or similar specialty.

Denial Risk

Nonclinical Weight or Age Target

Do not extend inpatient care solely to reach a target weight or specific PMA when physiologic discharge criteria are met.

AAP discharge guidance is based on physiologic competencies rather than a fixed weight or age.
Refer requests relying on a nonclinical weight or age target for physician review and discharge planning.

Unsupported block type: denial_risk

Unsupported block type: prior_auth

Unsupported block type: billing_rule

Policy Background

Bronchopulmonary dysplasia is a common chronic morbidity of very preterm birth. This policy uses the Jensen 2019 definition, which grades BPD according to the mode of respiratory support at 36 weeks postmenstrual age rather than oxygen exposure alone. Established BPD may be complicated by pulmonary hypertension, chronic ventilation, or tracheostomy, requiring coordinated respiratory, cardiac, discharge, and caregiver-readiness planning.

Clinical Definitions

BPD grade (Jensen 2019)

Assessment timeBPD grade is determined at 36 weeks PMA.

No BPDNo respiratory support.

Grade 1Nasal cannula at 2 L/min or less.

Grade 2Nasal cannula above 2 L/min or noninvasive positive airway pressure.

Grade 3Invasive mechanical ventilation.

BPD-associated pulmonary hypertension

ConditionPulmonary hypertension in an infant with BPD.

Diagnostic methodIdentified on echocardiography or catheterization.

Clinical relevancePulmonary hypertension may affect the infant's level of care and discharge planning.

Jensen definition of bronchopulmonary dysplasia

Definition basisBPD severity is categorized according to the mode of respiratory support.

Assessment timeRespiratory support is assessed at 36 weeks postmenstrual age.

Oxygen useThe categorization applies regardless of supplemental oxygen use.