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Code Condition Criteria Assigned Delivery of an infant born < or = 36 6/7 weeks gestation Early Term Delivery Delivery of an infant born > or = 37 0/7 and < or = 38 6/7 weeks gestation. 151 Infant Child (<24 m) Small for Gestational Age* (*Presence of disease or disorder diagnosed by physician as self-reported by applicant/participant/caregiver; or as reported by a physician, or someone working under a physician’s orders.) System or CPA Assigned 153 Infant Large for Gestational Age* Birth weight > or = to 9 lbs. (> or = to 4,000 g) (*Presence of disease or disorder diagnosed by physician as self-reported by applicant/participant/ caregiver; or as reported by a physician, or someone working under a physician’s orders.) CPA Assigned 201 Pregnant BF NBF Infant Child Low Hematocrit/Low Hemoglobin Pregnant: Non-Smoking Smoking 1 up to 2 packs per day < 11.0 hgb (0-13 w) < 11.5 hgb (0-13 w) < 10.5 hgb (14-26 w) < 11.0 hgb (14-26 w) < 11.0 hgb (27-40 w) < 11.5 hgb (27-40 w) Smoking up to <1 pack per day Smoking 2 packs plus per day < 11.3 hgb (0-13 w) < 11.7 hgb (0-13 w) < 10.8 hgb (14-26 w) < 11.2 hgb (14-26 w) < 11.3 hgb (27-40 w) < 11.7 hgb (27-40 w) BF, NBF: Non-Smoking Smoking 1 up to 2 packs per day < 11.8 hgb 8 to < 12 y < 12.3 hgb 8 to < 12 y < 11.8 hgb 12 to < 15 y < 12.3 hgb 12 to < 15 y < 12.0 hgb 15 to < 18 y < 12.5 hgb 15 to < 18 y < 12.0 hgb ≥18 y < 12.5 hgb ≥18 y Smoking up to <1 pack per day Smoking 2 packs plus per day < 12.1 hgb/hct 8 to < 12 y < 12.5 hgb 8 to < 12 y < 12.1 hgb 12 to < 15 y < 12.5 hgb 12 to < 15 y < 12.3 hgb 15 to < 18 y < 12.7 hgb 15 to < 18 y < 12.3 hgb ≥18 y < 12.7 hgb/hct ≥18 y Infant/Child: System Assigned High-risk Pregnant: Non-smoking; smoking up to < 1 pack/day; smoking 1 up to 2 packs/day; smoking 2 packs/day + HR ≤10.0 hgb (0-40 w) 201 + 371 High risk Pregnant BF, NBF: Non-smoking; smoking up to < 1 pack/day; smoking 1 up to 2 packs/day; smoking 2 packs/day + HR ≤10.0 hgb Infant (6 to 12 months of age): HR: Hgb (g): < or = to 9.5 Effective 8/2020