Description:
Home phototherapy is frequently used in the management of physiologic hyperbilirubinemia in the healthy term newborn. Phototherapy can be delivered using a special phototherapy lamp positioned over the baby’s bed; a fiberoptic system also can be used. For example, a fiberoptic cable attached to a transparent flat mat can be placed in direct contact with the infant’s skin. Fiberoptic phototherapy may be preferred by some, since exposure during feeding is not interrupted and protective eye pads are not needed.

Policy:
Home phototherapy with a fluorescent, tungsten-halogen lamp or fiberoptic system may be considered MEDICALLY NECESSARY for a healthy infant at 35 weeks' or more gestation with neonatal jaundice with a total serum bilirubin level of greater than 13 mg/dL but not requiring "intensive phototherapy," in whom pathologic jaundice has been ruled out.

Policy Guidelines: 
The 2004 guidelines issued by the American Academy of Pediatrics (AAP) define "intensive phototherapy" as "irradiance in the blue-green spectrum (wavelengths of approximately 430 – 490 nm) of at least 30 μW/cm2 per nm (measured at the infant’s skin directly below the center of the phototherapy unit) and delivered to as much of the infant’s surface area as possible." The AAP also notes "the most effective light sources currently commercially available for phototherapy are those that use special blue fluorescent tubes or a specially designed light-emitting diode light." The blue-green spectrum light is recommended because it "penetrates skin well and is absorbed maximally by bilirubin." To decrease the distance between the light source and the infant and to increase the surface area of exposure, there are commercial systems available that "provide phototherapy above and below the infant." This can occur with special blue fluorescent tubes or by placing "fiber-optic pads below an infant with phototherapy lamps above."

The 2004 AAP guidelines note phototherapy is considered "optional" in infants meeting the criteria for home therapy. Therefore, Plans may wish to carefully consider the medical necessity for requests for home phototherapy. Alternatively, it is recognized that the AAP guidelines are a conservative approach to home phototherapy, and some physicians may elect to treat some infants, particularly older infants, who would otherwise meet the AAP criteria for hospital-based phototherapy, with phototherapy in the home. 

Home phototherapy with more than one device, i.e., 2 fiberoptic systems, or a fluorescent lamp in conjunction with a fiberoptic system, may result in a more rapid decline in total serum bilirubin. However, hospitalization may be recommended for infants with higher bilirubin concentrations and risk factors requiring intensive phototherapy (as specified in the Rationale section).

Rationale:
While fluorescent lamps have been the most commonly used method of phototherapy treatment of hyperbilirubinemia, fiberoptic systems have also become available. Comparative studies have suggested that the decline in TSB in those using the fiberoptic system may not be as rapid as those using conventional fluorescent lights — which in one study consisted of seven overhead lamps. Tan reported on a study of 165 term health infants and 105 preterm infants with nonhemolytic hyperbilirubinemia who were assigned to receive either a fiberoptic blanket, overhead lamps or a combination of the two. (1) In term infants, the 24-hour TSB decline rate for fiberoptic, conventional and combined therapy was 9.2 percent, 21.5 percent and 29.9 percent, respectively. The decrease in efficacy of the fiberoptic system alone was thought to be related to the small size of the mat. In a subsequent 1997 study, Tan compared the efficacy of several different sizes of fiberoptic mats (standard, large or two standard mats) and conventional phototherapy with 24 declines of 10.26 percent, 14 percent, 21 percent and 19 percent, respectively. (2) However, both of these studies were done in the setting of the neonatal intensive care unit. In this setting, the speed of decline of the TSB might be clinically significant. However, the significance of the different rates of decline is uncertain in the home setting, where, by definition, the infants do not need intensive phototherapy and monitoring.

2004 Update:
This update focuses on the 2004 guidelines for the management of hyperbilirubinemia in the healthy term newborn published by the American Academy of Pediatrics (AAP). The AAP first published guidelines for the management of hyperbilirubinemia in 1994, (3) which were reaffirmed in 2000. In 2004, the AAP updated these guidelines and provided new provisions for phototherapy, including when home phototherapy would be appropriate and when phototherapy may be discontinued. (4) The updated guidelines focus on infants 35 weeks or more in gestation and specify that TSB levels be assessed in relation to the age of the infant in hours and risk level. At 48 hours of age, intensive phototherapy should begin at TSB levels of 11 mg/dL, 13 mg/dL or 15 mg/dL or above for high-, medium- and low-risk infants, respectively. At 72 hours of age, levels of TSB in infants requiring intensive phototherapy rise to 13 mg/dL, 15 mg/dL and 18 mg/dL for high-, medium- and low-risk infants respectively.

The AAP indicates "intensive phototherapy implies the use of high levels of irradiance in the 430- to 490-nm band (usually 30 µW/cm² per nm or higher) delivered to as much of the infant’s surface area as possible." In addition, special blue fluorescent tubes or specially designed light-emitting diode lights that emit predominately blue-green spectrum light are noted to be most effective.

The AAP specifies that providing conventional phototherapy either in the hospital or at home is an "option" at TSB levels that are 2 – 3 mg/dL below the intensive therapy levels but only in infants without risk factors. Infants with hyperbilirubinemia and any risk factors do not have the option for home phototherapy and require intensive phototherapy in the hospital setting. The AAP notes this is because home phototherapy devices may not provide levels of irradiance or surface-area exposure comparable to hospital devices. The risk factors for intensive phototherapy, as specified in the guidelines, are as follows:

• Isoimmune hemolytic disease
• G6PD deficiency
• Asphyxia
• Significant lethargy
• Temperature instability
• Sepsis
• Acidosis

The previous AAP guidelines did not indicate when phototherapy should stop. The 2004 guidelines indicate there is no standard for when phototherapy may be discontinued, since the cause of the hyperbilirubinemia and the age of the infant when phototherapy started must be taken into consideration. However, the guidelines also indicate phototherapy should be discontinued when TSB levels reach < 13 – 14 mg/dL.

References:

1. Tan KL. Comparison of the efficacy of fiberoptic and conventional phototherapy for neonatal hyperbilirubinemia. J Pediatr 1994; 125(4):607-12.
2. Tan KL. Efficacy of bidirectional fiber-optic phototherapy for neonatal hyperbilirubinemia. Pediatrics 1997; 99(5):E13 (www.pediatrics.org/cgi/content/full/99/5/e13).
3. American Academy of Pediatrics. Practice parameter; Management of hyperbilirubinemia in the healthy term newborn. Pediatrics 1994; 94(4 pt 4):558-65.
4. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004; 114(1):297-316.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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01012024  NEW POLICY

03/27/2024 Annual review, no change to policy intent.