CG-MED-26 Neonatal Levels of Care

This policy addresses admission to and continued stay in neonatal levels of care, including general/well-baby nursery observation in the immediate postpartum period. Coverage is medically necessary when infants meet level-appropriate criteria—e.g., for general nursery: healthy, physiologically stable neonates cared for in a nursery or with maternal rooming-in; typically ≥2000 g birthweight and/or ≥35 weeks gestation and clinically stable; services may include phototherapy for hyperbilirubinemia without hemolysis and oral feeds for asymptomatic hypoglycemia without need for IV therapy. It is not medically necessary when these criteria are not met, and IV fluids/medications or antibiotics are not appropriate at the general/well-baby nursery level (which is not NICU care).

"Admission to and continued stay in appropriate neonatal levels of care are consideredmedically necessaryfor the following indications:"