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    v1.0.28
    OpenPayerPolicy UpdatesPediatrics/Neonatologynorthwood Home phototherapy Coverage Update | Open…
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    CurrentnorthwoodPolicy N/A

    Home phototherapy (Bilirubin light / Bili-blanket) coverage criteria

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    Governs coverage and medical necessity criteria for home phototherapy devices for newborns with hyperbilirubinemia; applies to infants >=35 weeks gestation and their treating practitioners requesting home phototherapy equipment and services.

    Policy Summary
    Payernorthwood
    PolicyHome phototherapy (Bilirubin light / Bili-blanket) coverage criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 2020
    Next Review DateMay 11, 2025
    Key ActionOrder the home phototherapy device (HCPCS E0202) from the treating practitioner and ensure a diagnostic evaluation and home care treatment plan are in place before initiating therapy.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    >=35min gestational age
    14-18bilirubin selection range
    E0202equipment code
    >48 hrsage threshold

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    Coverage Criteria for Home Phototherapy

    Covered when ALL of the following are met

    Home phototherapy is considered reasonable and necessary when ALL of the following are satisfied:

    Primary requirements: 1) Ordered by the member's treating practitioner; 2) Infant >= 35 weeks gestation and older than 48 hours; otherwise healthy; 3) Normal physical examination (no significant abnormalities; no significant weight loss); 4) Actively feeding by breast or bottle with no evidence of dehydration; 5) Stooling and voiding by 24 hours of age; 6) Serum bilirubin concentration >14 mg/dL but <18 mg/dL OR meets age-specific consideration thresholds; 7) Diagnostic evaluation negative per required testing list; 8) Adequate home and parental environment; 9) Device ordered in conjunction with a home care treatment plan.

    Numeric bilirubin thresholds and diagnostic testing detailed in accompanying nodes.

    Age-specific bilirubin consideration thresholds

    Consider phototherapy when total serum bilirubin meets or exceeds these age-based thresholds:

    Age thresholds: 25-48 hours: total serum bilirubin >= 12 mg/dL (170 µmol/L); 49-72 hours: >= 15 mg/dL (260 µmol/L); >72 hours: >= 17 mg/dL (290 µmol/L).see text

    Policy also lists an overall selection guideline of serum bilirubin >14 mg/dL but <18 mg/dL as a separate numeric range.

    Pre-therapy diagnostic evaluation requirements

    Diagnostic evaluation prior to therapy must include ALL of the following:

    Diagnostic tests: History and physical examination; hemoglobin concentration or hematocrit; WBC count and differential; blood smear for red cell morphology and platelets; reticulocyte count; total and direct-reacting bilirubin concentration; maternal and infant blood typing and Coombs test; urinalysis including test for reducing substances.

    These tests must be performed and be negative/acceptable per policy selection guideline 2.h before home phototherapy is initiated.

    Infants whose elevated bilirubin is attributable to a primary hepatic disorder are specifically excluded from consideration for home phototherapy under this policy. The policy states that home phototherapy is reasonable and necessary only when the infant’s elevated bilirubin is not due to a primary hepatic disorder.

    This document includes a references list citing systematic reviews and USPSTF guidance on screening for bilirubin encephalopathy, and a detailed change/authorization history tracking annual reviews and editorial changes over time. The references cited include Trikalinos et al. and the US Preventive Services Task Force recommendation statement. The revision history documents multiple annual reviews and specific edits such as adding Aetna CPB to references, changing the gestational age requirement (from 37 to 35 weeks), and adding NCD/LCD verbiage to the Important Note.

    A determination that a product or service is reasonable and necessary under this policy does not by itself establish coverage. Final coverage and benefit determinations depend on the terms, conditions, limitations, and exclusions of the member’s contract; where contract language and policy conflict, the contract prevails.

    Within the provided excerpts there are no explicit statements labeling specific services or items as not medically necessary. The policy excerpts reference clinical evidence and screening guidance but do not include standalone not-medically-necessary declarations in the sections reviewed.

    Coding and Clinical Thresholds

    HCPCS Level II CodesHCPCSCovered
    E0202Bilirubin (phototherapy) light with photometer
    HCPCS Level II CodesHCPCS
    No codes listed
    inv-09: Serum bilirubin thresholds by age
    Age 25-48 hoursConsider phototherapy when total serum bilirubin >= 12 mg/dL (170 µmol/L).
    Age 49-72 hoursConsider phototherapy when total serum bilirubin >= 15 mg/dL (260 µmol/L).
    >72 hoursConsider phototherapy when total serum bilirubin >= 17 mg/dL (290 µmol/L).

    Provider Actions, Orders, and Authorization

    Prior Authorization

    Order device (HCPCS E0202) with treating practitioner's order and home care plan

    The home phototherapy device (HCPCS E0202) must be ordered by the member's treating practitioner and the device must be ordered in conjunction with a home care treatment plan that meets the member selection guidelines.

    • Equipment code: HCPCS E0202 (Bilirubin (phototherapy) light with photometer).
    • Order must be placed by the treating practitioner and paired with a home care treatment plan.
    Prior Authorization

    No additional explicit prior authorization requirements in excerpts

    The provided document excerpts do not state any additional explicit prior authorization requirements beyond the requirement that the device be ordered by the treating practitioner with a home care treatment plan.

    Step Therapy

    No step therapy required; home phototherapy alternative to inpatient care

    No step therapy requirements are specified in the policy excerpts; home phototherapy is presented as an alternative to inpatient treatment when the coverage criteria are met.

    Step Therapy

    No step therapy requirements specified in this portion

    This portion of the document does not specify any step therapy requirements.

    Documentation Required

    Ordering practitioner and required pre-therapy diagnostic evaluation

    The treating practitioner must order therapy and a diagnostic evaluation must be completed prior to initiating home phototherapy; required tests are listed explicitly.

    • History and physical examination.
    • Hemoglobin concentration or hematocrit.
    • WBC count and differential.
    • Blood smear for red cell morphology and platelets.
    • Reticulocyte count.
    • Total and direct-reacting bilirubin concentration.
    • Maternal and infant blood typing and Coombs test.
    • Urinalysis including a test for reducing substances.
    Documentation Required

    Change/authorization history present; no specific provider documentation requirements stated

    The document contains change/authorization history entries and review notes, but the excerpts do not state specific provider documentation requirements beyond ordering and completing the required diagnostic evaluation.

    Denial Risk

    Coverage determinations subject to member contract and plan limits

    Coverage determinations are made on a case-by-case basis and are subject to the terms, conditions, limitations, and exclusions of the member's contract; a finding that a service is reasonable and necessary does not itself constitute coverage.

    • Final benefit determinations depend on applicable contract language; contract language prevails over medical policy in conflicts.
    Denial Risk

    No explicit denial triggers present in excerpts

    No explicit denial triggers are described in the provided document excerpts.

    Background

    Home phototherapy delivers light energy to reduce circulating unconjugated bilirubin in neonates by photoisomerization and related photochemical processes. It is intended as an outpatient alternative to inpatient phototherapy for otherwise healthy infants who meet specified selection criteria, including a minimum gestational age (typically >= 35 weeks), clinical stability on exam, adequate feeding and hydration, supportive home environment, and appropriate diagnostic evaluation prior to initiation. The treatment is provided using a phototherapy light source such as a lamp, panel, or specialized fiberoptic "bili-blanket," and when provided must be ordered by the treating practitioner in conjunction with a home care treatment plan.

    Definitions

    inv-19: Home phototherapy (bili-blanket / phototherapy light) definition
    DefinitionHome phototherapy is treatment of the newborn in the home setting involving exposure to a phototherapy light source (lamp, light panel, or special light blanket) for management of elevated bilirubin (hyperbilirubinemia).
    Settings and devicesTherapy may be delivered via a lamp, light panel, or fiberoptic/special light blanket (bili-blanket).
    OrderingDevice must be ordered by the treating practitioner and in conjunction with a home care treatment plan per coverage criteria.
    inv-20: Bilirubin encephalopathy screening references
    Systematic review referenceTrikalinos TA et al., Systematic review of screening for bilirubin encephalopathy in neonates. Pediatrics. 2009;124(4):1162-1171.
    USPSTF recommendation statementUS Preventive Services Task Force; AHRQ. Screening of infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy: USPSTF recommendation statement. Pediatrics. 2009;124(4):1172-1177.
    PurposeReferences support screening of infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy (bilirubin encephalopathy).
    Policy Summary
    Payernorthwood
    PolicyHome phototherapy (Bilirubin light / Bili-blanket) coverage criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 2020
    Next Review DateMay 11, 2025
    Key ActionOrder the home phototherapy device (HCPCS E0202) from the treating practitioner and ensure a diagnostic evaluation and home care treatment plan are in place before initiating therapy.
    SourceLink
    On This Page
    Coverage Criteria for Home PhototherapyCoding and Clinical ThresholdsProvider Actions, Orders, and AuthorizationBackgroundDefinitions