Policy/Criteria:
It is the policy of health plans affiliated with Centene Corporation that the following
ultrasounds during pregnancy are considered medically necessary when the following conditions are met,
I. Standard first trimester ultrasound (76801)
II. Standard second or third trimester ultrasound (76805)
III.Detailed anatomic ultrasound (76811)
IV. Transvaginal ultrasound (76817)
V. Not medically necessary conditions
I. One standard first trimester ultrasound (76801) is allowed per pregnancy.
Subsequent standard first trimester ultrasounds are considered not medically necessary as a limited or follow-up ultrasound assessment (76815 or 76816) should be sufficient to provide a re-examination of suspected concerns.
II. One standard second or third trimester ultrasound (76805) is allowed per pregnancy.
Subsequent standard second or third trimester ultrasounds are considered not medically necessary as a limited or follow-up ultrasound assessment (76815 or 76816) should be sufficient to provide a re-examination of suspected concerns.
III.One detailed anatomic ultrasound (76811) is allowed per pregnancy when performed to evaluate for suspected anomaly based on history, laboratory abnormalities, or clinical evaluation; or when there are suspicious results from a limited or standard ultrasound.
Further indications include the possibility of fetal growth restriction and multifetal gestation. This ultrasound must be billed with an appropriate high risk diagnosis code. See below,
A second detailed anatomic ultrasound is considered medically necessary if a new maternal fetal medicine specialist group is taking over care, a second opinion is required, or the patient has been transferred to a tertiary care center in anticipation of delivery of an anomalous fetus requiring specialized neonatal care.
Further anatomic ultrasounds are considered not medically necessary as there is inadequate evidence of the clinical utility of multiple detailed fetal anatomic examinations.
IV. Transvaginal ultrasounds (TVU) are considered medically necessary when conducted in the first trimester for the same indications as a standard first trimester ultrasound, and later in pregnancy to assess cervical length, location of the placenta in women with placenta previa, or after an inconclusive transabdominal ultrasound. Cervical length screening is conducted for women with a history of preterm labor or to monitor a shortened cervix based on below information,
Up to 12 transvaginal ultrasounds are allowed per pregnancy.
Berghella approach to TVU measurement of cervical length for screening singleton gestations
Past pregnancy history
1. Prior preterm birth, 14 to 27 weeks
2. Prior preterm birth 28 to 36 weeks
3. No prior preterm birth
TVU cervical length screening
1. Start at 14 weeks and end at 24 weeks
2. Start at 16 weeks and end at 24 weeks
3. One exam between 18 and 24 weeks
Frequency
1. Every 2 weeks as long as cervix is at least 30 mm*
2. Every 2 weeks as long as cervix is at least 30 mm*
3. Once
Maximum # of TVU
1. 6
2. 5
3. 1
* Increase frequency to weekly in women with TVU cervical length of 25 to 29 mm. If <25 mm before 24 weeks, consider cerclage.
V. 3D and 4D ultrasounds are considered investigational and are therefore not medically necessary. Studies lack sufficient evidence that they alter management over twodimensional ultrasound in a fashion that improves outcomes.
The following additional procedures are considered not medically necessary:
- Ultrasounds performed solely to determine the sex of the fetus or to provide parents with photographs of the fetus;
- Scans for growth evaluation performed less than 2 weeks apart;
- Ultrasound to confirm pregnancy in the absence of other indications;
- A follow-up ultrasound in the first trimester in the absence of pain or bleeding.
Classifications of fetal ultrasounds include:
I. Standard First Trimester Ultrasound – 76801:
A standard first trimester ultrasound is performed before 14 weeks and 0 days of gestation. It can be performed transabdominally, transvaginally, or transperineally. When performed transvaginally, CPT 76817 should be used. It includes an evaluation of the presence, size, location, and number of gestational sac(s); and an evaluation of the gestational sac(s).
Indications for a first trimester ultrasound include the following:
- To confirm an intrauterine pregnancy
- To evaluate a suspected ectopic pregnancy
- To evaluate vaginal bleeding
- To evaluate pelvic pain
- To estimate gestational age
- To diagnose and evaluate multiple gestations
- To confirm cardiac activity
- As adjunct to chorionic villus sampling, embryo transfer, or localization and removal of an intrauterine device
- To assess for certain fetal anomalies, such as anencephaly, in high risk patients
- To evaluate maternal pelvic or adnexal masses or uterine abnormalities
- To screen for fetal aneuploidy (nuchal translucency) when a part of aneuploidy screening
- To evaluate suspected hydatidiform mole
II. Standard Second or Third Trimester Ultrasound – 76805:
A standard ultrasound in the second or third trimester involves an evaluation of fetal presentation and number, amniotic fluid volume, cardiac activity, placental position, fetal biometry, and an anatomic survey.
Indications for a standard second or third trimester ultrasound include the following:
- Screening for fetal anomalies
- Evaluation of fetal anatomy
- Estimation of gestational age
- Evaluation of fetal growth
- Evaluation of vaginal bleeding
- Evaluation of cervical insufficiency
- Evaluation of abdominal and pelvic pain
- Determination of fetal presentation
- Evaluation of suspected multiple gestation
- Adjunct to amniocentesis or other procedure
- Evaluation of discrepancy between uterine size and clinical dates
- Evaluation of pelvic mass
- Examination of suspected hydatidiform mole
- Adjunct to cervical cerclage placement
- Evaluation of suspected ectopic pregnancy
- Evaluation of suspected fetal death
- Evaluation of suspected uterine abnormality
- Evaluation of fetal well-being
- Evaluation of suspected amniotic fluid abnormalities
- Evaluation of suspected placental abruption
- Adjunct to external cephalic version
- Evaluation of prelabor rupture of membranes or premature labor
- Evaluation for abnormal biochemical markers
- Follow-up evaluation of a fetal anomaly
- Follow-up evaluation of placental location for suspected placenta previa
- Evaluation with a history of previous congenital anomaly
- Evaluation of fetal condition in late registrants for prenatal care
- Assessment for findings that may increase the risk of aneuploidy
III.Detailed Anatomic Ultrasound – 76811:
A detailed anatomic ultrasound is performed when there is an increased risk of an anomaly based on the history, laboratory abnormalities, or the results of the limited or standard ultrasound.
IV. Other Ultrasounds – 76817:
A transvaginal ultrasound of a pregnant uterus can be performed in the first trimester of pregnancy and later in a pregnancy to evaluate cervical length and the position of the placenta relative to the internal cervical os. When this exam is done in the first trimester, the same indications for a standard first trimester ultrasound, 76801.
High risk diagnosis code for Ultrasound:
B06.00 – B06.9 Rubella [German measles]
B50.0 – B54 Malaria
B97.6 Parvovirus as the cause of diseases classified elsewhere
E66.01 Morbid (severe) obesity due to excess calories [severe obesity with a BMI of 35 or >]
O09.511 – O09.519 Supervision of elderly primigravida
O09.521 – O09.529 Supervision of elderly multigravida
O09.811 – O09.819 Supervision of pregnancy resulting from assisted reproductive technology
O24.011 – O24.019, Diabetes mellitus in pregnancy
O24.111 – O24.119, Diabetes mellitus in pregnancy
O24.311 – O24.319, Diabetes mellitus in pregnancy
O24.811 – O24.819, Diabetes mellitus in pregnancy
O24.911 – O24.919 Diabetes mellitus in pregnancy
O30.001 – O30.099 Twin pregnancy
O30.101 – O30.199 Triplet pregnancy
O30.201 – O30.299 Quadruplet pregnancy
O30.801 – O30.899 Other specified multiple gestation
O31.10x+ – O31.23x+ Continuing pregnancy after spontaneous abortion / intrauterine death of one fetus or more
O33.6xx+ Maternal care for disproportion due to hydrocephalic fetus
O33.7xx+ Maternal care for disproportion due to other fetal deformities
O35.0xx+ Maternal care for (suspected) central nervous system malformation in fetus
O35.1xx+ Maternal care for (suspected) chromosomal abnormality in fetus
O35.2xx+ Maternal care for (suspected) hereditary disease in fetus
O35.3xx+ Maternal care for (suspected) damage to fetus from viral disease in mother
O35.4xx+ Maternal care for (suspected) damage to fetus from alcohol
O35.5xx+ Maternal care for (suspected) damage to fetus by drugs
O35.6xx+ Maternal care for (suspected) damage to fetus by radiation
O35.8xx+ Maternal care for other (suspected) fetal abnormality and damage
O35.9xx+ Maternal care for (suspected) fetal abnormality and damage, unspecified
O36.011+ – O36.099+ Maternal care for rhesus isoimmunization
O36.111+ – O36.199+ Maternal care for other isoimmunization
O36.511+ – O36.599+ Maternal care for other known or suspected poor fetal growth
O40.1xx+ – O40.9xx+ Polyhydramnios
O41.00x+ – O41.03x+ Oligohydramnios
O69.81x+ – O69.89x+ Labor and delivery complicated by other cord complications
O71.9 Obstetric trauma, unspecified
O76 Abnormality in fetal heart rate and rhythm complicating labor and delivery
O98.311 – O98.319 Other maternal infectious and parasitic diseases complicating pregnancy
O98.411 – O98.419 Other maternal infectious and parasitic diseases complicating pregnancy
O98.511 – O98.519 Other maternal infectious and parasitic diseases complicating pregnancy
O98.611 – O98.619 Other maternal infectious and parasitic diseases complicating pregnancy
O98.711 – O98.719 Other maternal infectious and parasitic diseases complicating pregnancy
O98.811 – O98.819 Other maternal infectious and parasitic diseases complicating pregnancy
O99.320 – O99.323 Drug use complicating pregnancy
O99.411 – O99.419 Diseases of the circulatory system complicating pregnancy
Q04.8 Other specified congenital malformations of brain [choroid plexuscyst]
Q30.1 Agenesis and underdevelopment of nose [absent or hypoplastic nasalbone]
Q62.0 Congenital hydronephrosis [fetal pyelectasis]
Q71.811 – Q71.819 Congenital shortening of upper limb [humerus]
Q72.811 – Q72.819 Congenital shortening of lower limb [femur]
Q92.0 – Q92.9 Other trisomies and partial trisomies of the autosomes, not elsewhere classified [fetuses with soft sonographic markers of aneuploidy]
R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum
R93.8 Abnormal findings on diagnostic imaging of other specified body structures
Z68.35 – Z68.45 Body mass index (BMI) 35.0 – 70 or greater, adult