Clinical UM Guideline



Subject: Neonatal Levels of Care
Guideline #:  CG-MED-26 Current Effective Date:    09/27/2017
Status: Revised Last Review Date:    08/03/2017

Description

This document addresses neonatal levels of care. Hospitals vary in the type of newborn care they provide. Not all facilities are capable of providing all types of care needed for sick newborns. The American Academy of Pediatrics (AAP) has defined the levels of care (LOC) required for the normal healthy newborn to the critically ill newborn. These LOC correspond to the therapies and services provided in each nursery. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification. All LOC described in this document are based upon clinical care needs and are not dependent upon the physical location of the infant within the health care facility or the name of the unit where the care is delivered.

A medically necessary neonatal level of care indicates the intensity of services needed or rendered based on an infant's clinical status and is not the same as AAP levels of nursery designation, which are based on the facility clinical service capabilities.

Clinical Indications

Medically Necessary:

Admission to and continued stay in appropriate neonatal levels of care are considered medically necessary for the following indications: 

General Nursery or Well-Baby Nursery:

This level of care is for healthy neonates who are physiologically stable and receiving evaluation and observation in the immediate post-partum period. Infants weighing 2000 grams or more at birth and clinically stable infants at 35 weeks gestational age or greater may be cared for in a well-baby nursery. This is not a neonatal intensive care level. Phototherapy, intravenous (IV) fluids or medications and antibiotic therapy are not appropriate for General Nursery or Well-Baby Nursery level of care.

Examples of types of services neonates receive or clinical conditions managed at this level of care are:

Level I Surveillance Special Care Nursery:

This level of care covers neonates who are medically stable but require surveillance/care at a higher level than provided in the general nursery.

Examples of types of services neonates receive or clinical conditions managed at this level are:

Level II Neonatal Intensive Care:

Newborns admitted or treated at this level are those with physiological immaturity combined with medical instabilities.

Examples of types of services neonates receive or clinical conditions managed at this level of care are:

Level III Neonatal Intensive Care:

This level of care is directed at those neonates that require invasive therapies and/or are critically ill with respiratory, circulatory, metabolic or hematologic instabilities and/or require surgical intervention with general anesthesia. 

Examples of types of services neonates receive or clinical conditions managed at this level of care are:

Level IV Neonatal Intensive Care:

This level of care covers hemodynamically unstable or critically ill neonates including those with respiratory, circulatory, metabolic or hemolytic instabilities, as well as conditions that require surgical intervention, and the first 24 hours of monitoring of infants with major congenital anomalies or extreme prematurity who are at risk for hemodynamic instability. 

Examples of types of services neonates receive or clinical conditions managed at this level of care are:

Not Medically Necessary:

Admission to and continued stay in appropriate neonatal levels of care are considered not medically necessary when the above criteria are not met.

Coding

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Discussion/General Information

Hospitals with obstetric services must also care for the newborn. In most cases, newborns do not require care beyond that of a general nursery. However, newborn complications can occur even when an uneventful birth is anticipated. It is important that facilities have equipment and capabilities to address these events or the process to stabilize and transport the ill newborn to a facility that does. The high-risk neonate is a newborn who has encountered an event in prenatal, perinatal, or postnatal life that leads to a high probability of manifesting a physiological or psychological deficit that requires admission to a neonatal intensive care unit (NICU).

Complications requiring a NICU admission can occur in premature and term infants. Infants born between 37 and 42 weeks of pregnancy are considered full term. Those born before 37 completed weeks of pregnancy are considered premature or late preterm. A late preterm infant is a premature baby born between 34 and 36 weeks gestational age. This is relatively close to full term, which is 37 weeks or greater (Engle, 2007).

For 2015, the Centers for Disease Control and Prevention (CDC) (Martin, 2017) reported that preterm birth (less than 37 completed week's gestation) affected about 1 of every 10 infants born in the United States (9.63%). Of those, the early preterm birth rate (less than 34 weeks) was essentially stable at 2.76% in 2015 and was down from 2.93% in 2007. The late preterm birth rate (34–36 weeks) rose slightly from 6.82% to 6.87%. A small rise in the percentage of infants born low birth weight (less than 2,500 grams) was also seen from 2014 to 2015, from 8.00% to 8.07%.

Newborn complications include, but are not limited to:

In 2012, the AAP issued a policy statement outlining the designations of levels of neonatal care to distinguish and standardize newborn care capabilities offered by hospitals. The AAP designations consist of levels I-IV and encompass all newborn care, from general care of the healthy newborn to care of the critically ill newborn. Each level reflects the minimal capabilities, functional criteria, and provider type required.

However, examples of medically necessary levels of neonatal care (such as hyperalimentation and treatment of apnea/bradycardia) noted in this document indicate the intensity of services needed or rendered based on an infant's clinical status as described by expert clinical input and are not the same as AAP designations, which are based on the facility clinical service capabilities.

Hudak and colleagues (2012) for the AAP released a neonatal drug withdrawal report indicating the predominant tool used in the United States to quantify the severity of neonatal withdrawal is the modified Neonatal Abstinence Scoring System. The system assigns a cumulative score based on the interval observation of 21 items relating to signs of neonatal withdrawal. Signs of neonatal withdrawal scored on the tool include central nervous system disturbances, metabolic/vasomotor/respiratory disturbances, and gastro-intestinal disturbances.

A prospective randomized controlled trial by Yoder and colleagues (2013) assessed the safety and efficacy of heated, humidified high-flow nasal cannula (HHHFNC) as compared to nasal continuous positive airway pressure (nCPAP) for noninvasive respiratory support in the newborn intensive care unit. A total of 432 infants ranging from 28 to 42 weeks' gestational age were enrolled in the study. Inclusion criteria included a birth weight of at least 1000 grams and gestational age at least 28 weeks, and randomization to either noninvasive (no endotracheal tube) respiratory support from birth initiated in the first 24 hours of life or noninvasive respiratory support at any age after a period of mechanical ventilation with an endotracheal tube. Exclusion criteria included a birth weight less than1000 grams, gestational age less than 28 weeks, presence of active air leak syndrome, concurrent participation in a study that prohibited HHHFNC, abnormalities of upper and lower airways, or serious abdominal, cardiac, or respiratory malformations including tracheal esophageal fistula, intestinal atresia, omphalocele, gastroschisis, or diaphragmatic hernia. The primary study outcome was defined as a need for intubation within 72 hours of applied noninvasive therapy. There was no difference in early failure for HHHFNC versus nCPAP, subsequent need for any intubation or in any of several adverse outcomes analyzed, including air leak. HHHFNC infants remained on the study mode significantly longer than nCPAP infants (median: 4 vs 2 days, respectively; P < 0.01), however, there were no differences between study groups for days on supplemental oxygen (median: 10 vs 8 days), bronchopulmonary dysplasia (20% vs 16%), or hospital discharge on oxygen (19% vs 18%). The authors concluded "additional large randomized trials are needed to evaluate the use of HHHFNC among smaller preterm infants as well as to compare different devices for and approaches to administering HHHFNC."

Definitions

Finnegan neonatal abstinence scoring system (modified): A system that assigns a cumulative score based on the interval observation of the following 21 items related to signs of neonatal drug withdrawal:

SIGNS AND SYMPTOMS SCORE

CENTRAL NERVOUS SYSTEM

Continuous High Pitched (or other) Cry 2-if high-pitched up to 5 minutes
3-if high-pitched for more than 5 minutes
Sleep 3-sleeps less than 1 hour after feeding
2-sleeps less than 2 hours after feeding
1-sleeps less than 3 hours after feeding
Moro Reflex 2-if hyperactive
3-if markedly hyperactive
Tremors 1-mild tremors disturbed
2-moderate-severe tremors disturbed
3-mild tremors undisturbed
4-moderate to severe tremors undisturbed
Increased Muscle Tone 2
Excoriation (Specific Area) 1
Myoclonic Jerks 3
Generalized Convulsions 5

METABOLIC/VASOMOTOR/RESPIRATORY DISTURBANCES

Sweating 1
Fever 1-if 100.4°-101°F (38°-38.3°C)
2-if more than 101°F (38.3°C)
Frequent Yawning (More than 3-4 times/interval) 1
Mottling 1
Nasal Stuffiness 1
Sneezing (More than 3-4 times/interval) 1
Nasal Flaring 2
Respiratory Rate 1-if more than 60/minute
2-if more than 60/minute with retractions

GASTROINTESTINAL DISTURBANCES

Excessive Sucking 1
Poor feeding 2
Regurgitation 2
Projectile Vomiting 3
Stools 2-if loose
3-if watery

(Finnegan, 1990; Hudak [AAP], 2012)

References

Peer Reviewed Publications:

  1. Abrahams RR, Kelly SA, Payne S, et al. Rooming-in compared with standard care for newborns of mothers using methadone or heroin. Can Fam Physician. 2007; 53(10):1722-1730.
  2. Phibbs CS, Baker LC, Caughey AB, et al. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med. 2007; 356(21):2165-2175.
  3. Tyson JE, Parikh NA, Langer J, et al. Intensive care for extreme prematurity--moving beyond gestational age.  N Engl J Med. 2008; 358(16):1672-1681.
  4. Yoder BA, Stoddard RA, Li M, et al. Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics. 2013; 131(5):e1482-1490. 

 Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Pediatrics (AAP), Committee on Fetus and Newborn. Levels of neonatal care. Pediatrics 2012; 130(3):587-597. Available at: http://pediatrics.aappublications.org/content/130/3/587.full.pdf. Accessed on June 14, 2017.
  2. Behrman R, Kliegman R, Jenson. Nelson Textbook of Pediatrics, 17th ed., 2004 Saunders.
  3. Engle WA, Tomashek KM, Wallman C; Committee on Fetus and Newborn, American Academy of Pediatrics. "Late-preterm" infants: a population at risk. Pediatrics. 2007; 120(6):1390-1401. Available at: http://pediatrics.aappublications.org/cgi/reprint/120/6/1390. Accessed on June 14, 2017.
  4. Finnegan LP. Neonatal abstinence syndrome: assessment and pharmacotherapy. In: Nelson N, editor. Current therapy in neonatal-perinatal medicine. 2 ed. Ontario: BC Decker; 1990.                                            
  5. Hudak ML, Tan RC; Committee on Drugs; Committee on Fetus and Newborn; American Academy of Pediatrics. Neonatal drug withdrawal. Pediatrics. 2012 (Errata 2014); 129(2):e540-560. Available at: http://pediatrics.aappublications.org/content/129/2/e540.full.pdf+html. Accessed on June 14, 2017.
  6. Martin JA, Hamilton BE, Osterman MJ, et al. Births: Final Data for 2015. Natl Vital Stat Rep. 2017; 66(1):1. Available at: https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_01.pdf . Accessed on June 15, 2017.
  7. Substance Abuse and Mental Health Services Administration. Advancing the care of pregnant and parenting women with opioid use disorder and their infants: A foundation for clinical guidance. Rockville, MD. 2016. Available at: http://files.www.cmhnetwork.org/news/Advancing_the_Care_of_Pregnant_and_Parenting_Women_with_Opioid_Use_Disorder_and_their_Infants_-_A_Foundation_for_Clinical_Guidance_-.pdf. Accessed on June 14, 2017.
Websites for Additional Information
  1. March of Dimes. Premature babies. 2013. Available at: http://www.marchofdimes.com/baby/premature_indepth.html. Accessed on June 14, 2017.
  2. National Institutes of Health (NIH). Preterm Labor and Birth. 2014. Available at: http://www.nichd.nih.gov/health/topics/preterm/Pages/default.aspx. Accessed on June 14, 2017.
Index

Levels of Care
Neonatal Intensive Care
NICU

History
Status Date Action
Revised 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Examples of levels of care in Clinical Indications section updated. Definition section added. Description, Discussion and References sections updated.
Revised 08/04/2016 MPTAC review. Removed abbreviation "i.e." and formatting updated in clinical indication section. Examples of level of care updated for Well-Baby Nursery and Level 1. References section updated.
Revised 08/06/2015 MPTAC review. Description and Reference sections updated. Example for Level II, infants transitioning home on a home ventilator clarified in medically necessary statement.
Revised 08/14/2014 MPTAC review. Examples for levels of care I, II, and III in medically necessary statement updated. Discussion, Links in Reference and Websites sections updated.
Revised 02/13/2014 MPTAC review. Examples for levels of care in medically necessary statement updated. Not medically necessary statement added. Discussion and Reference sections updated.
Revised 08/08/2013 MPTAC review. Medically necessary statement updated with "and continued stay in."
Revised 02/14/2013 MPTAC review. Levels in medically necessary statement updated. Description, Discussion and Reference sections updated.
Reviewed 02/16/2012 MPTAC review. References updated.
Reviewed 02/17/2011 MPTAC review. References updated.
Reviewed 02/25/2010 MPTAC review. References updated.
Reviewed 02/26/2009 MPTAC review. Case management section deleted, references updated.
Reviewed 02/21/2008 MPTAC review. References updated.
Revised 03/08/2007 MPTAC review. Criteria revised. References updated. 
Revised 06/08/2006 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Pre-Merger Organizations Last Review Date Guideline Number Title

Anthem, Inc.

    None
WellPoint Health Networks, Inc. 12/01/05 Guideline Neonatal Levels of Care