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2.5.12.2 Prior Authorization and Documentation Requirements
Home phototherapy devices require prior authorization and are provided only for the days that are medically necessary.
For low-risk infants, prior authorization will be considered for phototherapy services that begin in the home.
For stabilized infants who began phototherapy treatment during their hospitalization and have been discharged from the hospital, prior authorization will be considered for the continuation of phototherapy services in the home. Initial prior authorization may be given for a maximum of seven days of home phototherapy. A new "CCP Prior Authorization Request Form" must be submitted to request more than seven days of home phototherapy.
The following documentation is required to support medical necessity when requesting home phototherapy services:
• A diagnostic evaluation, which must include, but is not limited to, a normal history and physical exam, and normal laboratory values for the following, as medically indicated:
•Complete blood count with differential
•Platelets
•Blood smear for red blood cell morphology
•Reticulocyte count
•Urinalysis
•Maternal and infant blood typing
•Coombs test
•TSB (in mg/dl)
•Gestational age
•Documentation of adequate infant hydration, as demonstrated by 4-6 wet diapers per day and 3-4 stools per day
•Documentation stating that infant weight loss does not exceed 10% of the infant's birth weight
•Physician's plan of care
•Anticipated number of days the client will need the phototherapy treatment
•Documentation of parental education regarding the importance of monitoring and follow-up
When requesting prior authorization for a hospitalized infant that requires continued home phototherapy, providers must submit documentation that indicates all pre-existing medium- or high-risk factors have resolved or stabilized.
Providers must submit the following additional documentation for prior authorization requests for previously hospitalized infants that require continued home phototherapy or for more than seven days of home phototherapy:
•TSB level greater than 13 mg/dl and trending downward. TSB levels less than 13 will require medical review to determine medical necessity.
Note: According to AAP guidelines, phototherapy may be discontinued when the TSB level falls below 13-14 mg/dl; however, exceptions to the guidelines may be considered. As a result, documentation must include the rationale for not discontinuing phototherapy when the TSB level drops below 13 mg/dl.
•Birth weight and current weight demonstrating weight gain.
Note: According to AAP guidelines, breast-fed infants are expected to gain 15-30 grams per day (1/2-1 ounce per day) through the first 2-3 months of life.
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