CG-DME-12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia

This policy addresses home phototherapy devices for treating neonatal hyperbilirubinemia. Coverage is medically necessary when the infant is ready for or already discharged, has no hyperbilirubinemia neurotoxicity risk factors, and the total serum bilirubin is no more than 1 mg/dL above the AAP phototherapy threshold; it is not covered if these criteria are not met or if more than one device (intensive phototherapy) is used at home.

"Home phototherapy devices are consideredmedically necessarywhenthe criteria below are met:"

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