Department: Medical Management Utilization Policy #: UM24 Effective Date: 02/01/1996. Medi-Cal Yes X No MCAP Yes X No TPA Yes No X

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1 Subject: HEALTH PLAN OF SAN JOAQUIN Neonatal Intensive Care Unit (NICU) Services Department: Medical Management Utilization Policy #: UM24 Effective Date: 02/01/1996 Committee/Approval Date: Review/Revision Dates: 07/99; 04/08; 10/08; 10/15; 07/16 Applies To: Medi-Cal Yes X No MCAP Yes X No TPA Yes No X PURPOSE To outline the process for inpatient admissions that require NICU level of care and identifying whether service are covered by California Children s Services (CCS) or (HPSJ). Not all facilities are able to provide all level of care required. HPSJ will assure that levels of care 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. DEFINITIONS California Children's Services (CCS): CCS is a state program for children with certain diseases or health problems. Through this program, children up to 21 years old can get the health care and services they need. 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 American Academy of Pediatrics (AAP) levels of nursery designation, which are based on the facility clinical service capabilities. POLICY A. The 's provider for Neonatal Intensive Care Unit (NICU) services are provided by contracted, licensed facilities. B. A transfer from one NICU to another requires parental and provider approval. C. HPSJ will maintain Memorandum of Understanding (MOU) with agencies specializing in providing specialty care for this population. Local agencies are: 1. California Children Services (CCS) 2. Valley Mountain Regional Center (VMRC) 3. Public Health (PH) D. HPSJ will assist the inpatient facility to refer to CCS for authorization. The Health Plan will follow-up and assist in obtaining hospital medical records for CCS eligibility review.

2 E. The Plan will comply with APL in regards to establishing level of care per AP- DRG and identifying facilities which are public (Attachment A) and private. PROCEDURE A. Admission Review Process 1. Notification of and inpatient admission and review of clinical documentation for appropriateness in meeting Millimen Care Guidelines (MCG) criteria will be in line with Policy UM If the hospital where delivery occurs is a non-contracted hospital, the neonate(s) and mother will be evaluated for transfer. 3. If the mother agrees to transfer of the neonate, but chooses to remain in the delivery hospital, then upon clearance from the attending physician a transfer will occur. 4. HPSJ evaluates Medical necessity for transportation needs according to MCG Criteria. 5. Out of area admissions will follow the aforementioned procedures. B. Medically Necessary: Admission to and continued stay in appropriate neonatal levels of care are considered medically necessary for the following indications: 1. General Nursery or Well-Baby Nursery: This level of care is for healthy neonates who are physiologically stable and under routine 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 and antibiotic therapy are not appropriate for this level of care. i. Oral (nipple) feedings for asymptomatic hypoglycemia not requiring subsequent IV therapy; ii. Routine tests, examples include, but are not limited to, bilirubin, blood glucose, blood type and Coombs, direct antiglobulin test (DAT), complete blood count (CBC) or oximetry. 2. Level I Surveillance i.e., '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. this level are: i. Apnea/Bradycardia

3 1. Oral pharmacologic therapy for a baby who has been apnea-free for at least 72 hours; or 2. Surveillance without pharmacological intervention and 48 hours or more since last episode requiring intervention. ii. Diagnostic work-up/surveillance, on an otherwise stable neonate where no therapy is initiated; iii. Hyperbilirubinemia requiring phototherapy; iv. Infants transferred from a higher level of care who are physiologically stable, breathing room air, in an open crib, and taking either no medications or on a stable or declining dose of oral medications and requiring observation to document successful nipple feeding; v. Initial sepsis evaluation (CBC, blood culture for an asymptomatic neonate); vi. Isolette/warmer for observation or convenience of access (adjunctive therapy) and no other level II, III or IV criteria present; vii. IV fluids at low to moderate rates (generally less than 50 ml/kg/day) in stable infants who are being weaned off of IV fluids and without other clinical conditions qualifying for a higher level of care (LOC); viii. Services rendered for Neonatal Abstinence Syndrome (withdrawal) scores less than 8; ix. Services rendered to growing premature infant without supplemental oxygen or IV fluid needs or environmental control needs (other than blankets, cap, swaddling, etc.); x. Services to improve poor breast or bottle feeding that is advancing to full volume feeds. 3. Level II Neonatal Intensive Care: Newborns admitted or treated at this level are those with physiological immaturity combined with medical instabilities. i. Infants born 32 weeks gestation or greater and under 35 weeks gestation or infants weighing 1500 grams or more who have physiologic immaturity and who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis. ii. Apnea/Bradycardia a. Apnea/Bradycardia episode requiring vigorous stimulation; or b. Oral pharmacologic treatment for apnea and/or bradycardic episodes when last episode requiring intervention was less than 72 hours ago. iii. Feedings for 30 minutes or less via an orally or nasally inserted tube, for example nasogastric, nasojejunal, or gastrostomy tube. iv. Incubator/Warmer a. Documented need for environmental control via an incubator/warmer for thermoregulation; or

4 b. Physiologically stable infants in the process of being weaned from an incubator/warmer to an open crib. v. IV Therapy a. IV fluids (inclusive of hyperalimentation) at high infusion rate (generally greater than or equal to 50 ml/kg/day); or b. IV heparin lock medications; or c. IV medications in a physiologically/clinically stable infant via PICC line or peripheral IV; or d. IV treatment of hypoglycemia. vi. Respiratory support a. High-flow nasal cannula with flow less than or equal to 2 liters per minute or continuous positive airway pressure (CPAP) less than or equal to 4 cm H 2 O pressure; or b. Supplemental oxygen via oxygen hood or nasal cannula when effective fraction of inspired oxygen (FiO 2 ) of less than or equal to 40% is sufficient to maintain acceptable blood oxygen saturation (SaO 2 ); or c. Infants transitioning to home on a home ventilator awaiting family teaching and/or placement availability. vii. Sepsis a. Initial sepsis evaluation (CBC, blood culture, and other blood tests or cultures) for an asymptomatic neonate and antibiotic treatment pending laboratory and/or culture results; or b. Sepsis suspected or documented with treatment (IV/IM [intramuscular] therapies) beyond the initial 48 hours of treatment. viii. Services rendered for Neonatal Abstinence Syndrome (NAS) when the score is greater than or equal to 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. i. Apnea and/or Bradycardia a. Episodes requiring IV pharmacologic treatment; or b. Self-refilling bag valve unit resuscitation ("bagging"); or c. Other intervention beyond vigorous stimulation (for example CPAP). ii. Blood or blood product transfusion; iii. Chest tube; iv. Exchange transfusion, partial or complete and up to 48 hours after exchange transfusion dependent on clinical stability; v. Feedings greater than 30 minutes via an orally or nasally inserted tube, for example, nasogastric, oralgastric, nasojejunal, or gastrostomy tube; vi. Hemodynamic instability (including hypertension)

5 a. Invasive hemodynamic monitoring and CNS pressure monitoring; or b. Requiring IV volume bolus therapy and/or inotropic or chronotrophic drugs, Ca++ channel blockers, and IV prostaglandin therapy. vii. Infants less than 32 weeks gestational age or less than 1500 grams birth weight for the first 24 hours of life; viii. IV Therapy a. Inborn error of metabolism requiring IV therapy or specialized formula until tolerating full enteral feeds; or b. IV bolus or continuous drip therapy for severe physiologic/metabolic instability; or c. Metabolic acidosis or alkalosis or electrolyte imbalance requiring IV therapy; or d. Seizures requiring IV therapy (this criterion includes IV glucose administration for seizures caused by hypoglycemia); or e. Short bowel or "dumping" syndrome requiring total parenteral nutrition (TPN) at 50 or greater ml/kg/day. ix. Respiratory Services a. High-flow nasal cannula with flow greater than 2 liters per minute or CPAP greater than 4 cm H 2 O pressure; or b. Positive pressure ventilator assistance with intubation and 24 hours post-ventilator care; or c. Supplemental oxygen via oxygen hood or nasal cannula when effective FiO 2 of greater than 40% is required to maintain acceptable SaO 2 or neonate is intubated (Note: Intubation in the delivery room [DR] when the endotracheal tube is removed prior to leaving the DR or brief intubation for administration of surfactant or deep tracheal suctioning does not meet level III criteria for intubation); or d. Infants on chronic ventilators who are not sufficiently stable to transition to home ventilators/homecare or long term care. x. Surgical conditions requiring general anesthesia and two days post-op; xi. xii. Therapies for retinopathy of prematurity (ROP); Umbilical Artery Catheters (UACs), Peripheral Artery Catheters (PACs), Umbilical Vein Catheters (UVCs) and/or Central Vein Catheters (CVCs) when used for active monitoring or arterial or venous pressures. 5. Level IV Neonatal Intensive Care: This level of care covers critically ill neonates with respiratory, circulatory, metabolic or hemolytic instabilities as well as conditions that require surgical intervention. i. Extracorporeal membrane oxygenation (ECMO)/nitric oxide (NO);

6 ii. iii. iv. High frequency ventilation (HFV) used when conventional mechanical ventilation fails; Hypothermia therapy for hypoxic-ischemic encephalopathy-total body or selective head cooling; Pre and post-surgical care for severe congenital malformations or acquired conditions such as gastroparesis, ventricular septal defect (VSD) or other heart defects or bowel perforation, that require the use of advanced technology and support. C. 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 or policy UM02. A. REFERENCE A. Welfare and Institutions Code section B. Welfare and Institutions Code section C. MMCD, APL Diagnosis Related Froups: Billing for Beneficiaries with California Children s Services Eligible Conditions and/or Medi-Cal Managed care D. DHCS, CMS Net Information Bulletin #426 E. MMCD, APL California Children s Services (CCS) Policy Regarding the Requirement That All CCS Applicants Shall Make Application to the Medi-Cal Program (Health and Safety Code Section ) F. MMCD, APL California Children Services Numbered Letters and Approval: Signatures on File DHCS Contract Deliverables Contract Reference Date of Approval DHCS Unit Contract Reference Date of Approval DHCS Unit A /26/16 Attachment A The California Designated Public Hospitals

7 UC Davis Medical Center UC Irvine Medical Center UC San Diego Medical Center UC San Francisco Medical Center UC Los Angeles Medical Center, including Santa Monica/UCLA Medical Center LA County Harbor/UCLA Medical Center LA County Olive View UCLA Medical Center LA County Rancho Los Amigos National Rehabilitation Center. LA County University of Southern California Medical Center. Alameda County Medical Center Arrowhead Regional Medical Center Contra Costa Regional Medical Center Kern Medical Center Natividad Medical Center Riverside County Regional Medical Center San Francisco General Hospital San Joaquin General Hospital San Mateo Medical Center Santa Clara Valley Medical Center Ventura County Medical Center