Neonatal Hyperbilirubinemia (CPB 0332, reviewed 2026-06-02)
Aetna considers G6PD testing medically necessary when an infant presents with severe hyperbilirubinemia or rapid bilirubin rise, jaundice of unknown cause with an atypical course, late-onset jaundice or significant hyperbilirubinemia in a formula-fed infant, unexpected hemolysis, or a family history or genetic ancestry associated with increased risk, and when the results will change management. Facility-based phototherapy is medically necessary when total serum bilirubin (TSB) is at or above the American Academy of Pediatrics (AAP, 2022) phototherapy treatment threshold, which incorporates gestational age and neurotoxicity risk factors such as gestational age less than 38 weeks, albumin less than 3 g/dL, isoimmune hemolytic disease, G6PD deficiency or other hemolytic conditions, sepsis, or significant clinical instability in the previous 24 hours. Home-based phototherapy is covered only when all listed criteria are met, including that the infant has been discharged, gestational age is 38 weeks or greater, age is 48 hours or greater, the infant is clinically well and feeding adequately, there are no known neurotoxicity risk factors, there was no previous phototherapy, TSB is no more than 1 mg/dL above the phototherapy threshold, TSB will be monitored daily, and an LED-based home phototherapy device will be available without delay. Exchange transfusion is medically necessary when TSB is at or above the exchange transfusion threshold or the infant has signs of acute bilirubin encephalopathy. Discontinuation of phototherapy is generally considered when TSB has decreased by at least 2 mg/dL below the hour-specific threshold at the start of phototherapy. The policy lists antenatal phenobarbital in red cell isoimmunized pregnant women, deep learning-based prediction, genotyping of BLVRA, SLCO1B1 and UGT1A1, massage therapy, end-tidal carbon monoxide measurement, metalloporphyrins, prebiotics and probiotics, transcutaneous bilirubin devices used during phototherapy, ursodeoxycholic acid, and zinc supplementation as experimental, investigational or unproven. Indications not meeting the criteria are considered not medically necessary.