Hospitals vary in the type of newborn care they provide. Not all facilities are able to provide all types of care needed for sick newborns. The American Academy of Pediatrics (AAP) has defined the levels of care required for the normal healthy newborn to the critically ill newborn. These levels of care correspond to the therapies and services provided in the general nursery and the intensive care nurseries. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing and or certification.

Medically Necessary: 

Admission to appropriate neonatal levels of care is considered medically necessary for the following indications: 

General Nursery Observation (Level I  AAP):
This level of care covers healthy neonates who are physiologically stable and under routine evaluation and observation in the immediate post-partum period. This is not a neonatal intensive care unit level of care. This level of care may include routine bilirubin and blood glucose testing.

Level I  Surveillance i.e., 'Special Care Nursery'  (Level IIa AAP):
This level of care covers neonates who are medically stable but require surveillance/care at a higher level than provided in the general nursery. Types of services neonates receive at this level are:

• Phototherapy;
• Services rendered for Neonatal Abstinence Syndrome (withdrawal) scores less than 8;
• Apnea/bradycardia surveillance without pharmacological intervention;
• Services to improve poor breast or bottle feeding that is advancing to full volume feeds;
• Temperature instability surveillance;
• Isolette/warmer for thermoregulation;
• Diagnostic work-up/surveillance, on an otherwise stable neonate;
• Initial sepsis evaluation (CBC, blood culture for an asymptomatic neonate);
• Services rendered to growing premature infant without supplemental oxygen or IV fluid needs.

Level II Neonatal Intensive Care Unit (Level IIa AAP):
Newborns admitted to this unit are those with physiological immaturity combined with medical instabilities. Examples of the care at this level are:

• IV heplock meds;
• IV fluids;
• Supplemental oxygen via oxygen hood or nasal cannula of less than 40%;
• Feeding via nasogastric, orogastric, nasojejunal, or gastrostomy tube;
• Oral pharmacologic treatment for apnea and/or bradycardic episodes;
• Sepsis evaluation with treatment (IV therapies);
• Services rendered for Neonatal Abstinence Syndrome (NAS) when the score is greater than or equal to 8.

Level III Neonatal Intensive Care Unit (LeveIIb/IIIa AAP):
This level of care is directed at those neonates that require invasive therapies such as:

• Supplemental oxygen via oxygen hood or nasal cannula of greater than 40% or intubated;
• Intravenous (IV) pharmacologic treatment for apnea and/or bradycardic episodes;
• Services for apnea or other conditions requiring assisted respiration;
• Positive pressure ventilatory assistance;
• Exchange transfusion, partial or complete;
• Central or peripheral hyperalimentation;
• Chest tube;
• IV bolus or continuous drip therapy for severe physiologic/metabolic instability;
• Maintenance of Umbilical Artery Catheters (UACs), Peripheral Artery Catheters (PACs), Umbilical Vein Catheters (UVCs) and/or Central Vein Catheters (CVCs).

Level IV Neonatal Intensive Care Unit (Levels,IIIb,IIIc AAP):
This level of care covers critically ill neonates with respiratory, circulatory, metabolic or hemolytic instabilities as well as conditions that require surgical intervention.  Examples of services provided at this level are:

• Extracoporeal Membrane Oxygenation (ECMO) / Nitric Oxide (NO);
• High Frequency Ventilation;
• Pre and post surgical care for severe congenital malformations or acquired conditions such as gastroschesis, ventricular septal defect (VSD) or bowel perforation, that require the use of advanced technology and support.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. 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.

Specific procedure and diagnosis coding does not apply to this guideline.

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 leads to a high probability of manifesting a physiological or psychological deficit that requires admission to a neonatal intensive care unit (NICU).

Complications requiring a NICU admission can occur in premature and term infants. Infants born between 37 and 42 weeks of pregnancy are considered full term. Those born before 37 completed weeks of pregnancy are considered premature or late preterm. A late preterm infant is a premature baby born between 34 and 36 weeks gestational age. This is relatively close to full term, which is 37 weeks or greater (Engle, 2007).

About 12 percent of babies in the United States are born preterm. Of those, the majority (70%) of premature babies are born between 34 and 36 weeks of gestation, 12% are born between 32 and 33 weeks gestation, 10% between 28 and 31 weeks and 6% at less than 28 weeks gestation.

Newborn complications include but are not limited to:

• Pulmonary disorders: Hyaline membrane disease, transient tachypnea, meconium aspiration, amniotic fluid aspiration, persistent pulmonary hypertension of the newborn, pneumonia, pneumothorax, bronchopulmonary dysplasia, atelectasis;
• Cardiac conditions: Congenital heart defects, cyanotic and acyanotic cardiac disease;
• Endocrine disorders: Infant of a diabetic mother;
• Genetic: Chromosomal anomalies (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.

Peer Reviewed Publications:

1. Behrman R, Kliegman R, Jenson. Nelson Textbook of Pediatrics, 17th ed., 2004 Saunders.
2. 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.
3. 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. 

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Pediatrics (AAP), Committee on Fetus and Newborn. Levels of neonatal care. Pediatrics 2004; 114:1341-1347. Available at: http://aappolicy.aappublications.org/cgi/reprint/pediatrics;114/5/1341.pdf. Accessed on January 20, 2011.
2. Engle WA, Tomashek KM, Wallman C; Committee on Fetus and Newborn, American Academy of Pediatrics. "Late-preterm" infants: a population at risk. Pediatrics. 2007; 120(6):1390-1401. Available at: http://pediatrics.aappublications.org/cgi/reprint/120/6/1390. Accessed on January 20, 2011.

1. March of Dimes. Preterm birth. Available at: http://www.marchofdimes.com/baby/premature_indepth.html .  Accessed on January 20, 2011.

Levels of Care
Neonatal Intensive Care
NICU