Clinical UM Guideline

 

Subject: Neonatal Levels of Care
Guideline #:  CG-MED-26 Publish Date:    12/12/2018
Status: Revised Last Review Date:    11/08/2018

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. Care may take place in a nursery or in the birth mother’s room (“maternal rooming-in”). 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).

The Centers for Disease Control and Prevention (CDC) (Martin, 2017) reported that for 2015 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.

In a recent Cochrane review (Wilkinson, 2016), the authors define high-flow nasal cannula (HFNC) delivery as the use of gas flows greater than 1 L/min, noting that “typically higher gas flows (e.g. 2 to 8 L/min) are used.”

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. Cornish KS, Hrabovsky M, Scott NW, et al. The short- and long-term effects on the visual system of children following exposure to maternal substance misuse in pregnancy. Am J Ophthalmol. 2013; 156(1):190-194.
  3. Grossman MR, Berkwitt AK, Osborn RR, et al. An Initiative to Improve the Quality of Care of Infants with Neonatal Abstinence Syndrome. Pediatrics. 2017; 139(6):e20163360.
  4. Gupta M, Mulvihill AO, Lascaratos G, et al. Nystagmus and reduced visual acuity secondary to drug exposure in utero: long-term follow up. J Pediatr Ophthalmol Strabismus. 2012; 49(1): 58-63.
  5. Holleman-Duray D, Kaupie D, Weiss MG. Heated humidified high-flow nasal cannula: use and a neonatal early extubation protocol. J Perinatol. 2007; (12):776-781.
  6. Holmes AV, Atwood EC, Wahlen B, et al. Rooming-in to treat neonatal abstinence syndrome: improved family-centered care at lower cost. Pediatrics. 2016;137(6):e20152929.
  7. Kadivar M, Mosayebi Z, Razi N, et al. High flow nasal cannulae versus nasal continuous positive airway pressure in neonates with respiratory distress syndrome managed with INSURE method: a randomized clinical trial. Iran J Med Sci. 2016; 41(6):494-500.
  8. Kirk AT, Alder SC, King JD. Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. J Perinatol. 2007; 27(9):572-578.
  9. O’Connor S, Vietze PM, Sherrod KB, et al. Reduced incidence of parenting inadequacy following rooming-in. Pediatrics. 1980;66(2):176-1828.
  10. 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.
  11. Shoemaker MT, Pierce MR, Yoder BA, DiGeronimo RJ. High flow nasal cannula versus nasal CPAP for neonatal respiratory disease: a retrospective study. J Perinatol. 2007; 27(2):85-91.
  12. 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.
  13. Wachman EM, Grossman M, Scheff DM, et al. Quality improvement initiative to improve inpatient outcomes for neonatal abstinence syndrome. J Perinatology. 2018; 38(8):1114-1122.
  14. 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. Hospital discharge of the high-risk neonate. Pediatrics. Pediatrics. 2008 (reaffirmed 2011); 122(5):1119-1126.
  2. 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 September 27, 2018.
  3. Baley J, Committee on Fetus and Newborn. American Academy of Pediatrics (AAP). Skin-to-skin care for term and preterm infants in the neonatal ICU. Pediatrics. 2015; 136(3):596-599.
  4. Behavioral Health Coordinating Council Subcommittee on Prescription Drug Abuse. Protecting our infants act: report to congress. 2017. Available at: https://www.samhsa.gov/sites/default/files/‌topics/‌specific_populations/protecting-our-infants-act-report-congress-2017.pdf. Accessed on September 27, 2018.
  5. Behrman R, Kliegman R, Jenson. Nelson Textbook of Pediatrics, 17th ed., 2004 Saunders.
  6. 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 September 27, 2018.
  7. Finnegan LP. Neonatal abstinence syndrome: assessment and pharmacotherapy. In: Nelson N, editor. Current therapy in neonatal-perinatal medicine. 2 ed. Ontario: BC Decker; 1990.
  8. 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 September 27, 2018.
  9. Ko JY, Wolicki S, Barfield WD, et al. CDC grand rounds: public health strategies to prevent neonatal abstinence syndrome. MMWR Morb Mortal Wkly Rep. 2017; 66(9):242-245.
  10. Lemyre B, Davis PG, De Paoli AG, Kirpalani H. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev. 2017;(2)CD003212.
  11. 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 September 27, 2018.
  12. Substance Abuse and Mental Health Services Administration (SAMHSA). Clinical guidance for treating pregnant and parenting women with opioid use disorder and their infants. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018 Jan. Available at: https://store.samhsa.gov/product/Clinical-Guidance-for-Treating-Pregnant-and-Parenting-Women-With-Opioid-Use-Disorder-and-Their-Infants/SMA18-5054. Accessed on September 27, 2018.
  13. Tieder JS, Bonkowsky JL, Etzel RA, et al. American Academy of Pediatrics. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. 2016; 137(5)pii:e20160590.
  14. Walsh MC, Crowley M, Wexelblatt S, et al. Ohio Perinatal Quality Collaborative improves care of neonatal narcotic abstinence syndrome. Pediatrics. 2018; 141(4).pii:e20170900.
  15. Weston PJ, Harris DL, Battin M, et al. Oral dextrose gel for the treatment of hypoglycaemia in newborn infants. Cochrane Database Syst Rev. 2016; (5):CD011027.
  16. Wilkinson D, Andersen C, O’Donnell CP, et al. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev. 2016; 2:CD006405.
Websites for Additional Information
  1. March of Dimes. Premature babies. 2013. Available at: http://www.marchofdimes.com/baby/premature_indepth.html. Accessed on September 27, 2018.
  2. National Institutes of Health (NIH). Preterm Labor and Birth. 2017. Available at: http://www.nichd.nih.gov/health/topics/preterm/Pages/default.aspx. Accessed on September 27, 2018.
Index

Levels of Care
Neonatal Intensive Care
NICU

History

Status

Date

Action

Revised

11/08/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Examples of levels of care for General Nursery, Level I, Level II, and Level III updated in Clinical Indications section. Discussion/General Information, References, and Websites sections updated.

Reviewed

07/26/2018

MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” References and Websites sections updated.

Revised

08/03/2017

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