Clinical UM Guideline

This document addresses levels of care for neonates who meet criteria for inpatient care under applicable inpatient care guidelines. Hospitals vary in the type of newborn care they provide. Not all facilities are capable of providing all types of care needed for sick newborns. The American Academy of Pediatrics (AAP) has defined the levels of care (LOC) required for the normal healthy newborn to the critically ill newborn. These LOC 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. All LOC described in this document are based upon clinical care needs and are not dependent upon the physical location of the infant within the health care facility or the name of the unit where the care is delivered.

A 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 AAP levels of nursery designation, which are based on the facility clinical service capabilities.

Medically Necessary:

Admission to and continued stay in appropriate neonatal levels of care are considered medically necessary for the following indications:

General Nursery or Well-Baby Nursery:

This level of care is for healthy neonates who are physiologically stable and receiving evaluation and observation in the immediate post-partum period. Care may take place in a nursery or in the birth mother’s room (“maternal rooming-in”). 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 or medications and antibiotic therapy are not appropriate for General Nursery or Well-Baby Nursery level of care.

Examples of types of services neonates receive or clinical conditions managed at this level of care are:

• Oral (nipple) feedings for asymptomatic hypoglycemia not requiring subsequent IV therapy;
• Treatment of asymptomatic hypoglycemia with oral glucose gel;
• Laboratory tests (examples include, but are not limited to, bilirubin, blood glucose, blood type, direct antiglobulin test [DAT] also known as the direct Coombs test, complete blood count [CBC], C-reactive protein, screening blood culture) or oximetry when no therapy is given;
• Observation for development of signs of neonatal abstinence syndrome in an infant with known antenatal exposure to opioids or benzodiazepines. Well-Baby Nursery level of care excludes pharmacologic therapy of neonatal abstinence syndrome;
• Transient use of an external heat source to maintain temperature stability in an otherwise well infant;
• Routine transitional and stabilization care provided in the first 8 hours after birth;
• Infants who continue to require inpatient care but do not require a neonatal intensive care unit (NICU) level of care are suitable for care in a well-baby nursery.

Level I Surveillance 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.

Examples of types of services neonates receive or clinical conditions managed at this level are:

• Apnea/Bradycardia
  • Oral pharmacologic therapy for a baby who has been apnea-free for at least 72 hours; or
  • Surveillance without pharmacological intervention and 48 hours or more since last episode requiring intervention;
• Diagnostic work-up/surveillance, on an otherwise stable neonate, under 35 weeks gestational age, where no therapy is initiated;
• Hyperbilirubinemia requiring phototherapy;
• 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;
• Initial sepsis evaluation (for example, CBC, blood culture for an asymptomatic neonate receiving monitoring);
• Antibiotic administration pending culture results (48 hours of incubation) in asymptomatic infants with normal sepsis screening laboratory tests who are taking enteral feedings and IV is for antibiotic administration only;
• Isolette/warmer for observation or convenience of access (adjunctive therapy) and no other level II, III or IV criteria present;
• IV fluids and enteral feedings, as follows:
  • IV fluids administered at 50 ml/kg/day or less for routine fluid, electrolyte, glucose and nutritional purposes in stable infants who are being weaned off of IV fluids and receiving enteral feedings by any combination of nasogastric, gastrostomy or nipple feedings, without other clinical conditions qualifying for a higher level of care; or
  • Nipple feedings are greater than 50% of total enteral feedings;
• Services rendered for neonatal abstinence syndrome:
  • Continuation of medication weaning for infants whose neonatal abstinence scores are 8 or less; or
  • Non-pharmacologic management of neonatal abstinence scores by provision of a non-stimulating environment, which may include maternal rooming-in or care in a non-NICU setting;
• Services rendered to growing premature infant without supplemental oxygen or IV fluid needs or environmental control needs (other than blankets, cap, swaddling, etc.);
• Services rendered for stable infants on nasal cannula flow support, with or without supplemental oxygen, where clinical discharge milestones set by hospital are met and infant will be discharged with durable medical equipment (DME); parental training on DME should be completed while infant still requires hospitalization.

Level II Neonatal Intensive Care:

Newborns admitted or treated at this level are those with physiological immaturity combined with medical instabilities.

Examples of types of services neonates receive or clinical conditions managed at this level of care are:

• 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;
• Apnea or Bradycardia
  • Apnea or Bradycardia episode requiring stimulation; or
  • Oral pharmacologic treatment for apnea or bradycardic episodes when last episode requiring intervention was less than 72 hours ago;
• Enteral feedings as follows:
  • Enteral feedings via a feeding tube located within the duodenum or jejunum; or
  • In infants receiving gavage and nipple feedings, where the volume delivered by gavage feedings is at 50% or greater of the total enteral feeding volume;
• Incubator or Warmer therapies
  • Documented need for environmental control via an incubator/warmer for thermoregulation; or
  • Physiologically stable infants in the process of being weaned from an incubator/warmer to an open crib;
• IV Therapy
  • IV fluids, inclusive of total parenteral nutrition, greater than or equal to 50 ml/kg/day; or
  • IV heparin lock medications; or
  • IV medications in a physiologically/clinically stable infant via PICC line or peripheral IV; or
  • IV treatment of hypoglycemia;
• Respiratory support
  • 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 H₂O pressure; or
  • Supplemental oxygen via oxygen hood or nasal cannula when effective fraction of inspired oxygen (FiO₂) of less than or equal to 40% is sufficient to maintain acceptable blood oxygen saturation; or
  • Infants with stable respiratory status transitioning to home on a home ventilator awaiting family teaching and/or placement availability;
• Sepsis
  • 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
  • Sepsis suspected or documented with treatment (IV/IM [intramuscular] therapies) beyond the initial 48 hours of treatment;
• Pharmacologic treatment of neonatal abstinence syndrome
  • The score is greater than or equal to 8 and non-pharmacologic therapy has failed; or
  • Infant is unable to meet any one of the following parameters while provided supportive care in a non-stimulating environment:
    • Able to be breastfed or take greater than or equal to 1 ounce from a bottle per feed; or
    • Able to sleep undisturbed for greater than or equal to 1 hour; or
    • Able to be consoled within 10 minutes after the onset of crying.

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.

Examples of types of services neonates receive or clinical conditions managed at this level of care are:

• Apnea and/or Bradycardia
  • Episodes requiring IV pharmacologic treatment; or
  • Self-refilling bag valve unit resuscitation ("bagging"); or
  • Other intervention beyond vigorous stimulation (for example, CPAP);
• Blood or blood product transfusion;
• Chest tube;
• Exchange transfusion, partial or complete and up to 48 hours after exchange transfusion dependent on clinical stability;
• Feedings complicated by episodes of apnea, bradycardia, or desaturations requiring stimulation for recovery;
• Infants less than 32 weeks gestational age or less than 1500 gms birth weight for the first 24 hours of life;
• IV Therapy
  • Inborn error of metabolism requiring IV therapy or specialized formula until tolerating full enteral feeds; or
  • Metabolic acidosis or alkalosis or electrolyte imbalance requiring IV therapy; or
  • Seizures requiring IV therapy (this criterion includes IV glucose administration for seizures caused by hypoglycemia);
• Peritoneal dialysis on automated recycler;
• Respiratory Services
  • Nasal cannula with flow greater than 2 liters per minute or CPAP greater than 4 cm H₂O pressure; or
  • Positive pressure ventilator assistance with intubation and 24 hours post-ventilator care; or
  • Supplemental oxygen via oxygen hood or nasal cannula when effective FiO₂ of greater than 40% is required to maintain acceptable SaO₂ or neonate is intubated (Note: Intubation in the delivery room when the endotracheal tube is removed prior to leaving the delivery room or brief intubation for administration of surfactant or deep tracheal suctioning does not meet level III criteria for intubation); or
  • Nasal intermittent positive pressure ventilation; or
  • Infants on chronic ventilators who are not sufficiently stable to transition to home ventilators/homecare or long term care;
• Surgical conditions requiring general anesthesia and two days post-op;
• 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.

Level IV Neonatal Intensive Care:

This level of care covers hemodynamically unstable or critically ill neonates including those with respiratory, circulatory, metabolic or hemolytic instabilities, as well as conditions that require surgical intervention, and the first 24 hours of monitoring of infants with major congenital anomalies or extreme prematurity who are at risk for hemodynamic instability.

Examples of types of services neonates receive or clinical conditions managed at this level of care are:

• Extracorporeal membrane oxygenation (ECMO)/nitric oxide (NO);
• 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 gastroschisis, coarctation of the aorta or other heart defects or bowel perforation, that require the use of advanced technology and support;
• Continuous or closely monitored medication infusion where an interruption of the medication could result in hemodynamic instability or other severe morbidities; examples of such medications include, but are not limited to, prostaglandin E, vasoactive or inotropic drugs, and insulin;
• Hemodynamic instability (including hypertension)
  • Invasive hemodynamic monitoring and CNS pressure monitoring; or
  • Requiring IV volume bolus therapy and/or inotropic or chronotropic drugs, Ca++ channel blockers, and IV prostaglandin therapy;
• IV bolus or continuous drip therapy for severe physiologic/metabolic instability;
• Renal replacement therapy with any form of hemodialysis or filtration, or peritoneal dialysis until on automated recycler.

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.

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Hospitals with obstetric services must also care for the newborn. In most cases, newborns do not require care beyond that of a general nursery. However, newborn complications can occur even when an uneventful birth is anticipated. It is important that facilities have equipment and capabilities to address these events or the process to stabilize and transport the ill newborn to a facility that does. The high-risk neonate is a newborn who has encountered an event in prenatal, perinatal, or postnatal life that requires admission to a NICU.

Complications requiring a NICU admission can occur in premature and term infants. The AAP 2019 Clinical Report Updates on an At-Risk Population: Late-Preterm and Early-Term Infants (Stewart, 2019) defines infants born between 37 weeks and 38 weeks as early-term. Infants born between 39 weeks and 40 weeks are term, and those born at 41 weeks or later are late term. Infants born before 37 weeks are considered preterm or premature.

The Centers for Disease Control and Prevention (CDC) (2022) reported that for 2022, preterm birth (less than 37 completed week’s gestation) affected about 1 of every 10 infants born in the United States.

Newborn complications include, but are not limited to:

• Cardiac conditions: Congenital heart defects, cyanotic and acyanotic cardiac disease;
• Endocrine disorders: Infant of a diabetic mother;
• Genetic: Chromosomal anomalies (for example: Trisomy 13, 18, 21, Turner's);
• Gastrointestinal: Surgical emergencies such as necrotizing enterocolitis, perforated viscus, intestinal obstruction, diaphragmatic hernia, esophageal or gut atresia, gastroschisis, omphalocele, imperforate anus, esophageal atresia, tracheoesophageal fistula;
• Hematologic conditions: Indications for phototherapy, exchange transfusion in the premature or ill neonate, erythroblastosis fetalis, hydrops fetalis, and partial exchange transfusion for anemia or polycythemia;
• Infectious disease: Intrauterine viral infections, Group B Streptococcal infections, neonatal sepsis and meningitis, herpes simplex; infant of HIV, hepatitis, or syphilis; fungal infections;
• Neurologic disorders: Hypoxic-ischemic encephalopathy, intraventricular hemorrhage, retinopathy of prematurity, drug withdrawal, central apnea, seizures, hydrocephalus, spina bifida;
• Pulmonary disorders: Hyaline membrane disease (respiratory distress syndrome), transient tachypnea, meconium aspiration, amniotic fluid aspiration, persistent pulmonary hypertension of the newborn, pneumonia, pneumothorax, bronchopulmonary dysplasia, atelectasis.

In 2012 (reaffirmed 2015), the AAP issued a policy statement outlining the designations of levels of neonatal care to distinguish and standardize newborn care capabilities offered by hospitals. The AAP designations consist of levels I-IV and encompass all newborn care, from general care of the healthy newborn to care of the critically ill newborn. Each level reflects the minimal capabilities, functional criteria, and provider type required. However, examples of medically necessary levels of neonatal care (such as hyperalimentation and treatment of apnea/bradycardia) noted in this document indicate the intensity of services needed or rendered based on an infant’s clinical status as described by expert clinical input and are not the same as AAP designations, which are based on the facility clinical service capabilities.

In 2017 the AAP and American College of Obstetrics and Gynecology issued their Guidelines for Perinatal Care. In it they recommend that term and late-preterm infants be closely observed for the first 4-8 hours during the transition period following birth.

A 2020 study by Akangire and colleagues sought to decrease the use of antibiotics for suspected but not yet confirmed early-onset sepsis in neonates 34 weeks gestation or greater. The authors note that further research is necessary for neonates less than 34 weeks gestation.

Experienced clinicians advise that peritoneal dialysis on an automated recycler requires NICU level of care with renal replacement therapy handled at the highest level of NICU.

Consensus from experienced clinicians is that infants requiring nasal cannula flow of greater than 2 liters per minute may require the equivalent CPAP also greater than 4.

Patrick and colleagues (2020) for the AAP released a neonatal opioid withdrawal syndrome report. They indicate the most commonly used tool in the United States to quantify the severity of neonatal withdrawal is the modified Neonatal Abstinence Scoring System. The system assigns a cumulative score based on the interval observation of 21 items relating to signs of neonatal withdrawal. Signs of neonatal withdrawal scored on the tool include central nervous system disturbances, metabolic/vasomotor/respiratory disturbances, and gastro-intestinal disturbances. An alternative tool is called Eat, Sleep, Console (ESC). The aim of this scoring tool is to guide treatment by the infant’s clinical signs of withdrawal through their ability to eat, sleep undisturbed, and be consoled. Currently the ESC approach has only been studied through quality improvement initiatives and it is unclear if improvements are as a result of the ESC approach itself or from better adherence to nonpharmacologic management. Both the Neonatal Abstinence Score and the ESC method are in common use. Neither has been shown to be clinically superior to the other.

Finnegan neonatal abstinence scoring system (modified): A system that assigns a cumulative score based on the interval observation of the following 21 items related to signs of neonatal drug withdrawal:

(Finnegan, 1990; Patrick [AAP], 2020)

Peer Reviewed Publications:

1. Abrahams RR, Kelly SA, Payne S, et al. Rooming-in compared with standard care for newborns of mothers using methadone or heroin. Can Fam Physician. 2007; 53(10):1722-1730.
2. Akangire G, Simpson E, Weiner J, et al. Implementation of the neonatal sepsis calculator in early-onset sepsis and maternal chorioamnionitis. Adv Neonatal Care. 2020; 20(1):25-32.
3. Cornish KS, Hrabovsky M, Scott NW, et al. The short- and long-term effects on the visual system of children following exposure to maternal substance misuse in pregnancy. Am J Ophthalmol. 2013; 156(1):190-194.
4. Grossman MR, Berkwitt AK, Osborn RR, et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017; 139(6):e20163360.
5. Gupta M, Mulvihill AO, Lascaratos G, et al. Nystagmus and reduced visual acuity secondary to drug exposure in utero: long-term follow up. J Pediatr Ophthalmol Strabismus. 2012; 49(1): 58-63.
6. Holleman-Duray D, Kaupie D, Weiss MG. Heated humidified high-flow nasal cannula: use and a neonatal early extubation protocol. J Perinatol. 2007; (12):776-781.
7. Holmes AV, Atwood EC, Wahlen B, et al. Rooming-in to treat neonatal abstinence syndrome: improved family-centered care at lower cost. Pediatrics. 2016;137(6):e20152929.
8. Kadivar M, Mosayebi Z, Razi N, et al. High flow nasal cannulae versus nasal continuous positive airway pressure in neonates with respiratory distress syndrome managed with INSURE method: a randomized clinical trial. Iran J Med Sci. 2016; 41(6):494-500.
9. Kirk AT, Alder SC, King JD. Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. J Perinatol. 2007; 27(9):572-578.
10. Phibbs CS, Baker LC, Caughey AB, et al. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med. 2007; 356(21):2165-2175.
11. Shoemaker MT, Pierce MR, Yoder BA, DiGeronimo RJ. High flow nasal cannula versus nasal CPAP for neonatal respiratory disease: a retrospective study. J Perinatol. 2007; 27(2):85-91.
12. Tyson JE, Parikh NA, Langer J, et al. Intensive care for extreme prematurity--moving beyond gestational age. N Engl J Med. 2008; 358(16):1672-1681.
13. Wachman EM, Grossman M, Scheff DM, et al. Quality improvement initiative to improve inpatient outcomes for neonatal abstinence syndrome. J Perinatology. 2018; 38(8):1114-1122.
14. Yoder BA, Stoddard RA, Li M, et al. Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics. 2013; 131(5):e1482-1490.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Pediatrics (AAP), Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate. Pediatrics. 2008 (reaffirmed 2018); 122(5):1119-1126.
2. American Academy of Pediatrics (AAP), Committee on Fetus and Newborn. Levels of neonatal care. Pediatrics. 2012 (reaffirmed 2015); 130(3):587-597.
3. Baley J, Committee on Fetus and Newborn. Skin-to-skin care for term and preterm infants in the neonatal ICU. Pediatrics. 2015; 136(3):596-599.
4. Centers for Disease Control and Prevention (CDC). Preterm Birth. Last reviewed October 24, 2023. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm. Accessed on January 9, 2024.
5. Edwards T, Liu G, Hegarty JE, Oral dextrose gel to prevent hypoglycaemia in at-risk neonates. Cochrane Database Syst Rev. 2021; (5):CD012152.
6. Eichenwald EC, Committee on Fetus and Newborn. Apnea of prematurity. Pediatrics. 2016; 137(1); e20153757.
7. Finnegan LP. Neonatal abstinence syndrome: assessment and pharmacotherapy. In: Nelson N, editor. Current therapy in neonatal-perinatal medicine. 2 ed. Ontario: BC Decker; 1990.
8. Kilpatrick SJ, Papile L, Macones GA, Watterberg KL. Guidelines for Perinatal Care. 8th ed. American Academy of Pediatrics and American College of Obstetrics and Gynecology. 2017. Chapter 10: pp347. Care of the newborn.
9. Ko JY, Wolicki S, Barfield WD, et al. CDC grand rounds: public health strategies to prevent neonatal abstinence syndrome. MMWR Morb Mortal Wkly Rep. 2017; 66(9):242-245.
10. Lemyre B, Davis PG, De Paoli AG, Kirpalani H. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev. 2017;(2)CD003212.
11. Patrick SW, Barfield WD, Poindexter BB, AAP Committee on Fetus and Newborn, Committee on Substance Use and Prevention. Neonatal opioid withdrawal syndrome. Pediatrics. 2020; 146(5):e2020029074.
12. Stark AR, Pursley DM, Papile LA, et al. Standards for levels of neonatal care: II, III, and IV. Pediatrics. 2023; 151(6):e2023061957.
13. Stewart DL, Barfield WD, AAP Committee on Fetus and Newborn. Updates on an at-risk population: late-preterm and early-term infants. Pediatrics. 2019; 144(5):e20192760.
14. Substance Abuse and Mental Health Services Administration (SAMHSA). Clinical guidance for treating pregnant and parenting women with opioid use disorder and their infants. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018 Jan. Available at: https://store.samhsa.gov/product/Clinical-Guidance-for-Treating-Pregnant-and-Parenting-Women-With-Opioid-Use-Disorder-and-Their-Infants/SMA18-5054. Accessed on January 9, 2024.
15. Substance Abuse and Mental Health Services Administration (SAMHSA). Status report on Protecting our Infants Act implementation plan. 2019. Available at: https://aspe.hhs.gov/system/files/pdf/260891/POIA.pdf. Accessed on January 9, 2024.
16. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants. Pediatrics. 2016; 137(5)pii:e20160590.
17. Walsh MC, Crowley M, Wexelblatt S, et al. Ohio Perinatal Quality Collaborative improves care of neonatal narcotic abstinence syndrome. Pediatrics. 2018; 141(4).pii:e20170900.
18. Wilkinson D, Andersen C, O’Donnell CP, et al. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev. 2016; 2:CD006405.

1. March of Dimes. Premature babies. 2019. Available at: https://www.marchofdimes.org/find-support/topics/birth/premature-babies. Accessed on January 9, 2024.
2. National Institutes of Health (NIH). Preterm Labor and Birth. 2023. Available at: http://www.nichd.nih.gov/health/topics/preterm/Pages/default.aspx. Accessed on January 9, 2024.

Levels of Care
Neonatal Intensive Care
NICU

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