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Biophysical Fetal Profile

Policy Number: MP-232

Latest Review Date: February 2019

Category: Obstetrics                                                             

Policy Grade: Active Policy but no longer scheduled for regular literature reviews and updates.

Description of Procedure or Service:

The are many indications for antepartum fetal surveillance.  Common noninvasive tests are non stress tests (NST) and biophysical profiles (BPP).  These tests reflect conditions that are associated with increased fetal morbidity and mortality.  Conditions that lead to fetal hypoxia, uteroplacental insufficiency, and death are all indications for increased fetal surveillance. No absolute protocols have been established for increased fetal surveillance, but certain practices are accepted for given maternal-fetal risks. For example, weekly antenatal testing beginning the 32nd week of gestation is often performed in women with low to moderate risk, such as those with gestational diabetes, chronic hypertension, or mild preeclampsia. For women with a higher risk of abnormal outcome, earlier and more frequent antenatal testing may be indicated.

A reactive or reassuring NST is defined as one with at least two accelerations in a 20-minute period above the baseline fetal heart rate of 15 beats per minute for 15 seconds. If a reactive pattern is not present at the end of the first 20 minutes, attempts may be made to arouse the fetus. Fetal rest periods, which are reported to be 30 to 40 minutes in duration, must be excluded for the fetus to demonstrate a reactive NST. A nonreactive NST without fetal heart rate decelerations may not indicate fetal jeopardy, but may be an indication for further evaluation. This evaluation may include a biophysical profile (BPP).

A biophysical fetal profile (BPP) is an ultrasonographic assessment of fetal well-being. During the ultrasound, certain behavioral patterns associated with a healthy fetus are documented. The test has five different components, each worth two points (See table below). Indicators such as amniotic fluid volume, fetal breathing, fetal heart rate, movement, and tone are evaluated. A score of 8 or 10 is reassuring, a score of 6 is suspicious and indicates a need for further evaluation, and a score of 4 or less is ominous and indicates a need for immediate intervention. A low score may also reflect the fetus’s behavioral state during the test, such as normal sleep or sedation from maternal use of narcotics or central nervous system depressants. However, a decreasing score has been well correlated with poor outcome and with increasing degrees of fetal acidemia.

The modified BPP consists of the nonstress test (NST) and the amniotic fluid index. It can be just as useful for fetal surveillance in patients at increased risk for poor perinatal outcome and small-for-gestational-age infants.

Components of the Biophysical Profile

Parameter

Normal (Score = 2)

Abnormal (Score = 0)

Nonstress test

Two or more accelerations of at least 15 bpm above baseline for at least 15 sec in 20 minutes

Fewer than 2 accelerations of sufficient height and duration in 20 minutes

Amniotic fluid volume

At least 1 amniotic fluid pocket greater than or equal to 2 cm in vertical pocket or AFI of 5cm

No 2 × 2-cm pockets or AFI <5.0

Fetal breathing movements

1 or more episodes of rhythmic fetal breathing movements for at least 30 sec

Less than 30 sec of fetal breathing

Fetal body movements

At least 3 limb or gross body movements

Fewer than 3 limb or body movements

Fetal tone

Extremities in flexion at rest and at least 1 episode of extension of the extremity or spine with return to flexion

Extension at rest or no return to flexion after movement

NOTE: Scoring of the latter four components is done ultrasonographically in a 30-minute observation period. A total score of 8 to 10 is reassuring, a score of 6 is suspicious, and a score of 4 or less is ominous.

AFI, amniotic fluid index (the sum of the largest vertical pocket in each of four quadrants of the uterus).

Policy:

Fetal biophysical profile may be considered medically necessary for patients at or after 32 weeks gestation with an increased risk of fetal demise.  Conditions associated with an increase risk of fetal demise include:

  • Hypertensive disorders

  • Diabetes mellitus

  • Poorly controlled hyperthyroidism

  • Hemoglobinopathies (i.e. sickle cell diseases)

  • Cyanotic heart disease

  • Systemic lupus erythematosus

  • Antiphospholipid syndrome

  • Chronic renal disease

  • Hemorrhage

  • Thyroid disease

  • Severe hypoxic lung disease

  • Inflammatory bowel disease

  • Warfarin (Coumadin, Panwarfin)

  • Phenytoin (Dilantin)

  • Infections:

    • Syphilis

    • Cytomegalovirus

    • Toxoplasmosis

    • Rubella

    • Parvovirus B19

    • Hepatitis B

    • Herpes simplex virus (HSV-1 or HSV-2)

    • HIV-1

  • Substance abuse

  • Pregnancy-related conditions which might include:

    • Decreased fetal movement

    • Oligohydramnios

    • Polyhydramnios

    • Gestational diabetes

    • Intrauterine growth restriction

    • Post term pregnancy

    • Fetal cardiac arrhythmias

    • Fetal chromosomal anomalies

    • Previous fetal demise (unexplained or recurrent risk)

    • Multiple gestations with significant growth discrepancy.

Individual consideration will be given to extremely high-risk pregnancy for BPP to begin at 24 weeks gestation. 

Individual consideration will be given to BPPs performed more often that every seven days.  

Key Points:

In 2015, Booker et al evaluated antenala surveillance in twin pregnancies using the biophysical profile. Women with twin pregnancies delivered by a single maternal-fetal medicine practice from 2005 to 2013 were included. We excluded monoamniotic twins. Twin pregnancies began weekly sonography for the biophysical profile starting at 32 to 33 weeks, or earlier if indicated. The nonstress test was performed if the sonographic biophysical profile score was less than 8 of 8. We reviewed biophysical profile scores and outcomes for all patients who delivered at 33 weeks or later to assess the false-positive rate for the biophysical profile, as well as the incidence of intrauterine fetal death (IUFD) after initiation of antenatal surveillance.Results-A total of 539 twin pregnancies were included. The incidence of IUFD per patient was 2 per 539 (0.4%; 95% confidence interval [CI], 0.1%-1.3%), and the incidence of IUFD per fetus was 2 per 1078 (0.19%; 95% CI, 0.05%-0.7%). The overall positive screen rate was 24 per 539 (4.45%; 95% CI, 3.0%-6.5%). The false-positive screen rate, defined as an abnormal biophysical profile that did not diagnose an IUFD or lead to delivery, was 10 per 539 (1.9%; 95% CI, 1.0%-3.4%).  In twin pregnancies the use of the sonographic biophysical profile for routine antenatal surveillance has a low false-positive rate, with a very low incidence of IUFD. The sonographic biophysical profile should be considered as a primary mode for antenatal surveillance in twin pregnancies, with a reflex nonstress test for an abnormal score.

Manandhar et al (2013) published a prospective study evaluating the relationship of BPP with perinatal outcome in pregnant mothers with decreased fetal movement counts at or above 34 weeks of gestational age.  The study demonstrated that most of the fetuses were in good condition with 87% of the cases scoring 8-10 BPS (normal), 6% scoring six (equivocal) and only 7% got four score (abnormal). Having the abnormal BPS of four significantly increased the risk of perinatal mortality by 50% (p=0.000). However reduced fetal movements only did not raise the risk of fetal morbidity and mortality. BPP score should be beneficial to detect the fetuses at risk in the patients having less fetal movements for the proper management at right time.

In the past, many studies have used fetal biophysical testing, regardless of the underlying pathophysiologic condition.  Evidence-based observations have shown that there are different pathophysiologic processes that may place the fetus at risk and that the efficacy of the various fetal tests depends on the underlying pathophysiologic condition.  The pathophysiologic processes that can cause fetal death or damage are decrease uteroplacental blood flow, decreased gas exchange at the trophoblastic membrane level, metabolic processes, fetal sepsis, fetal anemia, fetal heart failure, and umbilical cord accidents.  Table II lists the conditions that can be associated with these pathophysiologic processes. 

Table II . Maternal/fetal conditions and their underlying pathophysiologic condition

Pathophysiologic process

Maternal/fetal condition

Decreased uteroplacental blood flow

Chronic hypertension

Preeclampsia

Collagen/renal/vascular disease

Most cases of fetal growth restriction (i.e., <32-34 wk)

Decreased gas exchange

Postdates pregnancy, some fetal growth restricted cases (i.e., >32-34 wk)

Metabolic aberrations

Fetal hyperglycemia

Fetal hyperinsulinemia

Fetal sepsis

PROM

Intra-amniotic infection

Maternal fever, primary subclinical intra-amniotic infection

Fetal anemia

Fetomaternal hemorrhage

Erythroblastosis fetalis

Parvovirus B19 infection

Fetal heart failure

Cardiac arrhythmia

Nonimmune hydrops

Placental chorioangioma

Aneurysm of the vein of Galen

Umbilical cord accident

Umbilical cord entanglement (monoamniotic twins)

Velamentous cord insertion/Funic presentation

Noncoiled umbilical cord

Oligohydramnios

Indications for Delivery based on the Biophysical Profile:

  • BPP<2

  • BPP=4 at >32 weeks

  • BPP=4<32 weeks; repeat same day; induce if <6

  • BPP=6 with normal amnionic fluid index (AFI), >36 weeks with favorable cervix

  • BPP=8 with oligohydramnios

  • BPP=6 at <36 weeks and cervix unfavorable; repeat in 24 hours; induce if <6; follow if >6

Practice Guidelines and Position Statements

The American College of Obstetricians and Gynecologists

ACOG published a practice bulletin in December 2016 regarding ultrasound in preganancy. They state that indication for specialized examinations, such as the biophysical profile, include fetal growth restriction and multifetal gestation.

In 2014, ACPG published a practice bulletin regarding antepartum fetal surveillance.

  • “In growth-retstricted fetuses, umbilical artery doppler velocimetry used in conjunction with standard fetal surveillance, such as NSTs or BPPS or both, is associated with improved outcomes (level A evidence)

  • Abnormal results from an NST or from a modified BPP generally shouldbe followed by additional testing with either a contraction stress test or BPP. (level B evidence)

  • Initiating antepartum fetal testing no earlier than 32 0/7 weeks of gestation is appropriate for most at risk patients. However, in pregnancies with multiple or particularly worrisome hig risk conditions (e.g. chronic hypertension with suspected fetal growth restriction), testing might begin at a gestational age when delivery would be considered for perinatal benefit.

  • When the clinical condition that prompted testing persists, the test should be repeated periodically to monitor for continued fetal well being until delivery. If the maternal medical condition is stable and test results are reassuring, tests of fetal well being (NST, BPP, modified BPP, or CST) are typically repeated at weekly intervals; however, in the presence of certain high risk conditions, some investigators have performed more frequent testing, although the optimal regimen has not been established (level C evidence).”

The American College of Radiology

According to the ACR, “The BPP is the mainstay of fetal well-being evaluation and consists of four parameters variably sensitive to the acute exposure of the fetus to hypoxemia….. For those at risk for fetal demise, testing strategies usually evaluate one or more of the fetal well-being parameters at least weekly. For the well-being of those fetuses at highest risk for fetal demise, testing can often occur twice weekly or even daily, from the point of postnatal viability until delivery is indicated.”

Key Words:

Biophysical profile, fetal biophysical profile, modified biophysical profile, BPP, fetal well being

Approved by Governing Bodies:

Not applicable

Benefit Application:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity. Special benefit consideration may apply.  Refer to member’s benefit plan.

Current Coding: 

CPT codes:

76818

Fetal biophysical profile; with non-stress testing

76819

;without non-stress testing

 

 

 

References:

  1. American College of Obstetricians and Gynecologists. Practice Bulletin: Antepartum fetal surveillance. Number 145, July 2014.

  2. American College of Obstetricians and Gynecologists. Practice Bulletin: Ultrasound in Pregnancy. Number 175, December 2016.

  3. American College of Radiology. ACR appropriateness criteria. Growth disturbances-risk of fetal growth restriction. https://acsearch.acr.org/docs/69377/Narrative/. Accessed Februaru 13, 2019.

  4. Booker W, Fox NS, Gupta S, et al. Antenatal Sureveillance in Twin Pregnancies using the Biophysical Profile. J Ultrasound Med. 2015 Nov;34(11):2071-5.

  5. Gardner MO and Doyle NM.  Asthma in pregnancy.  Obstet Gynecol Clin North Am 2004;31(2):385-413.

  6. Kontopoulos EV and Vintzileos AM.  Condition-specific antepartum fetal testing. Am J Obstet Gynecol 2004; 191(5): 1546-51.

  7. Lewis DF, Adair CD, et al.  A randomized clinical trial of daily nonstress testing versus biophysical profile in the management of preterm premature rupture of membranes.  Am J Obstet Gynecol 1999; 181(6). 

  8. Manandhar BL, Giri K, Rana A. Fetal biophysical profile score and perinatal outcome. J Nepal Health Res Counc. 2013 Sep; 11(25):269-72.

  9. Manning FA, Morrison I, et al.  Fetal assessment based on fetal biophysical profile scoring: experience in 12,620 referred high-risk pregnancies.  1985; 151(3): 343-50.

  10. Neff MJ.  ACOG releases guidelines on management of post-term pregnancy.  Am Fam Physician 2004; 70(11): 2221-25.

  11. Nageotte MP, Towers CV, et al.  The value of a negative antepartum test:  Contraction stress test and modified biophysical profile.  Obstet Gynecol 1004; 84(2): 231-34.

  12. Panting-Kemp A, Nguyen T, Castro L.  Substance abuse and polyhydramnios.  Am J Obstet Gynecol 2002; 187(3).

  13. Rakel: Textbook of Family Practice, 6th ed.  2002 W.B. Saunders Company.

  14. Schroeder BM.  ACOG practice bulletin on thyroid disease in pregnancy.  Am Fam Physician 2002; 65(10): 2158, 2161-62.

  15. Schroeder BM.  ACOG practice bulletin on diagnosing and managing preeclampsia and eclampsia.  Am Fam Physician 2002; 66(2): 330-31.

  16. Vandebosche RC and Kirchner JT.  Intrauterine growth retardation.  Am Fam Physician 1998; 58(6).

Policy History:

Medical Policy Group, June 2005 (2)

Medical Policy Administration Committee, July 2005

Available for comment July 28-September 10, 2005

Medical Policy Group, June 2008 (1)

Medical Policy Group, September 2012 (3): Effective September 14, 2012 this policy is no longer scheduled for regular literature reviews and updates.

Medical Policy Group, February 2019 (4):  Updates to Description, Key Points, and References.  Clarified policy statements by adding “Gestational DM” under pregnancy related conditions and removed “Insulin dependent” DM from conditions associated with an increase risk of fetal demise.


This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

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2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

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