Neonatal Hyperbilirubinemia

Covered: measurement of G6PD in jaundiced infants who are receiving phototherapy, responding poorly to phototherapy, or at increased risk, and phototherapy (including prophylactic for rise >1 mg/dL/hr and temporary use pending exchange) and exchange transfusion for term and near‑term infants when indicated per AAP age‑in‑hours total serum bilirubin (TSB) thresholds accounting for gestational age and specified risk factors (isoimmune hemolysis, G6PD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, or albumin <3.0 g/dL). Not covered: end‑tidal CO corrected for ambient CO (ETCOc), BLVRA/SLCO1B1/UGT1A1 genotyping, transcutaneous bilirubin devices during phototherapy, metalloporphyrins (e.g., stannsoporfin/tin mesoporphyrin), and antenatal phenobarbital.

"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 ag..."