Phototherapy for Neonatal Hyperbilirubinemia

This policy covers phototherapy (inpatient or home, including LED or single‑source blue‑green 460–490 nm devices) and universal screening for the treatment and prevention of neonatal hyperbilirubinemia per age‑specific TSB/AAP thresholds to avert BIND/kernicterus. Home therapy is limited to infants ≥38 weeks gestation and ≥48 hours old who are feeding well and clinically stable, have not had prior phototherapy, have a willing PCP with 12–24 hour follow‑up and daily TSB monitoring and immediate device availability; exclusions include isoimmune/hemolytic disease (positive DAT/G6PD), HIE, sepsis, temperature instability, birth weight <2500 g, significant weight loss, elevated direct bilirubin, and other listed clinical instability criteria.

"Home phototherapy for the treatment of neonatal hyperbilirubinemia when medically necessary to treat elevated total serum bilirubin (TSB) and prevent acute bilirubin-induced neurologic dysfunction ..."