P58.0 — Neonatal jaundice due to bruising
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Record of transcutaneous bilirubin (TcB) result when used for screening, with notation if infant is/was undergoing phototherapy (note: TcB is not reliable during phototherapy).
- Documentation of infant's age in hours, neurotoxicity risk factors, and indications used to initiate phototherapy or exchange transfusion (per AAP-derived thresholds).
- Clinical notes documenting response to phototherapy (improvement or poor response) to justify further testing (e.g., G6PD measurement) or escalation of care.
- Family history and ethnic/geographic origin documentation when assessing likelihood of G6PD deficiency (to support measurement of G6PD level).
Key Coverage Criteria
- Exchange transfusion for infants with bilirubin levels ≥ 25 mg/dL, those not responding to phototherapy, and infants with evidence of acute bilirubin encephalopathy (initiation based on infant's age in hours and neurotoxicity risk factors).
- Home-based phototherapy as an alternative to hospital-based phototherapy for treatment of neonatal hyperbilirubinemia (when appropriate and per device/clinical criteria; appears effective in reviewed studies).
- Intermittent phototherapy as an alternative to continuous phototherapy for treatment of neonatal hyperbilirubinemia (appears similarly effective and possibly safer in available studies).
- Use of transcutaneous bilirubin (TcB) devices for screening/evaluation of hyperbilirubinemia in term and near-term infants not undergoing phototherapy (screening modalities such as early TSB, TcB, and risk scores can predict hyperbilirubinemia, though impacts on long-term outcomes are uncertain).
- Measurement of G6PD level in a jaundiced infant who is receiving phototherapy when family history or ethnic/geographic origin suggests likely G6PD deficiency or when response to phototherapy is poor (per AAP guidance).
- Inpatient treatment for healthy full-term infants who present with a TSB greater than or equal to 20 mg/dL in the first post-natal week.
2 Active Policies
AETNA-CPB-0332 — Neonatal Hyperbilirubinemia
ANTHEM-CG-MED-49 — CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders
Related Codes
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