Rental of phototherapy devices for use in the home (procedure code L-E0202) will be a benefit of Texas Medicaid only through the Comprehensive Care Program (CCP) for low-risk infants. Low-risk infants are defined as being at least 35 weeks gestation at birth, without comorbidity, and with a total serum bilirubin (TSB) level within the following ranges:
|
Gestation at Birth |
TSB for 0-24 hours of age |
TSB for 25-48 hours of age |
TSB for 49-72 hours of age |
TSB for older than 72 hours of age |
|
35-37 weeks |
3-7 mg/dL |
7-13 mg/dL |
10-15 mg/dL |
13-18 mg/dL |
|
38 weeks or greater |
6-11 mg/dL |
12-15 mg/dL |
15-18 mg/dL |
18-21 mg/dL |
Home phototherapy for medium- and high-risk infants is not a benefit of Texas Medicaid. As defined by the American Academy of Pediatrics (AAP), medium- and high-risk infants should be considered for more extensive initial treatment in an inpatient setting. Medium- and high-risk infants include, but are not limited to, those who have at least one of the following known risk factors:
· Acidosis
· Albumin less than 3.0 g/dL
· Asphyxia
· Glucose-6-phosphate dehydrogenase (G6PD) deficiency
· Isoimmune hemolytic disease (blood group incompatibility)
· Jaundice within the first 24 hours
· Sepsis
· Significant lethargy
· Temperature instability
The durable medical equipment (DME) provider must perform routine maintenance and provide instructions to the parent or guardian on the safe use of the phototherapy device.
Skilled nursing visits for clients requiring phototherapy services may be reimbursed separately through Title XIX Home Health Services for nonroutine clinical teaching and assessment. Routine laboratory specimens are obtained during the skilled nursing visit, and may be considered only when the alternative to obtaining the specimen is to transport the client by ambulance.
If a client that is receiving private duty nursing (PDN) services requires phototherapy, instructions in the use of the equipment must be part of the existing PDN authorized hours. Skilled nursing visits will not be allowed on the same day as PDN services.
Rental of a phototherapy device (procedure code L-E0202) is limited to one per day for any provider.
Prior Authorization Requirements
Prior authorization requests for home phototherapy devices must be submitted on the THSteps-CCP Prior Authorization Request Form. 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 “THSteps-CCP Prior Authorization Request Form” must be submitted to request more than seven days of home phototherapy.
When requesting home phototherapy services, providers must submit the following documentation to support medical necessity:
· A diagnostic evaluation, which should include, but is not limited to, a normal history and physical exam with normal laboratory values, as medically indicated, for the following:
o Complete blood count with differential.
o Platelets.
o Blood smear for red blood cell morphology.
o Reticulocyte count.
o Urinalysis.
o Maternal and infant blood typing.
o Coombs test.
· TSB (in mg/dL).
· Gestational age.
· Documentation of adequate infant hydration, as demonstrated by four to six wet diapers per day and three to four stools per day.
· Documentation stating that infant weight loss does not exceed 10 percent 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 in 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 preexisting medium- or high-risk factors have resolved or stabilized.
Providers must submit the following additional documentation for prior authorization requests for previously hospitalized infants who require continued home phototherapy or for more than 7 days of home phototherapy:
· TSB level greater than 13 mg/dL and trending downward. TSB levels lower than 13 mg/dL will require medical review to determine medical necessity.
Note: According to American Association of Pediatrics (AAP) guidelines, phototherapy may be discontinued when the TSB level falls below 13 to 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, breastfed infants are expected to gain 15 to 30 grams per day (1/2 to 1 ounce per day) through the first 2 to 3 months of life.