mp-016 - mp-016 - Medical Policies
Ultrasounds in Maternity Care
Policy Number: MP-016
Latest Review Date: August 2021
Policy Grade: A
Effective for dates of service on or after March 1, 2017:
Ultrasounds in maternity care may be considered medically necessary for normal pregnancy when up to two ultrasounds are performed per pregnancy in the outpatient setting, including the Emergency Department.
Appropriate use of ultrasounds for normal pregnancy would be between 6-10 weeks’ gestation for dating purposes and between 16-22 weeks’ gestation to determine organ development and fetal anatomy.
In some cases, the pregnancy may be considered high risk during the first two ultrasounds and the patient’s condition may improve as the pregnancy progresses. In those cases, if the non-routine ultrasounds are performed between 6-10 weeks or 16-20 weeks gestation, they should yield information regarding dating and fetal anatomy. Additional routine ultrasounds are considered not medically necessary.
Ultrasounds in excess of two for normal pregnancy are considered not medically necessary.
Follow up ultrasound for non-routine (high-risk) conditions possibly affecting the outcome of the pregnancy may be considered medically necessary.
The following criteria are used to determine if a non-routine ultrasound meets medical criteria for coverage:
- Ultrasounds to determine fetal growth less than or greater than gestational age should only be performed if there is a discrepancy of two or more weeks in fundal height and gestational age documented on two consecutive visits.
- When indicated, maternity ultrasounds performed for fetal growth may be considered medically necessary when performed at least 4 weeks apart. An exception will be made for fetuses with an estimated fetal weight (EFW) by USG of less than the 15th percentile. In those cases, obstetrical USG’s for estimated fetal weight meet for coverage when performed at least 2 to 3 weeks apart.
- Advanced maternal age is defined as age 35 or over.
- Obesity is defined as 100 or more pounds over ideal body weight (as determined by the Metropolitan Height and Weight Table).
- Ultrasounds for decreased fetal movement would may be considered medically necessary after a failed kick-count. These ultrasounds would not be medically necessary in early gestation (less than 20 weeks).
- Multiple Gestation;
- Serial ultrasounds every 2-3 weeks beginning at 16 weeks.
- Serial ultrasounds every 4-6 weeks beginning at 20 weeks.
- Three or more fetuses:
- appropriate monthly until 24 weeks, every two weeks until 32 weeks, weekly after 32 weeks until delivery
- Ultrasounds may be considered medically necessary for patients with diabetes mellitus which was present prior to pregnancy and for patients with gestational diabetes requiring insulin or oral agents for maximum blood glucose control every 4 weeks beginning at week 28
- Patients on antihypertensive medication or with elevated blood pressure could have an ultrasound every 4 weeks beginning with week 28
- One ultrasound in the last month of pregnancy can be performed to verify a breech or other malpositioned fetus
- In women with abnormal AFP, if the ultrasound at 16-22 weeks’ gestation is normal, it is not medically necessary to repeat the ultrasound in the absence of any other indications
- Follow up ultrasounds for asymptomatic placenta previa noted on ultrasound is not indicated until the third trimester and only if the placenta previa is complete or marginal on a previous ultrasound.
Medical records may be audited on a post payment basis to determine if the above criteria have been met or if the diagnosis code has been reported accurately. Refunds may be requested based on the results of these audits.
The use of three-dimensional (3D) ultrasound (use of CPT codes 76376 or 76377 with 76801-76817) is considered not medically necessary. If only a 3D study is performed, the two-dimensional portion of the ultrasound is covered per the above criteria.
Transvaginal and transabdominal ultrasounds performed on the same date of service are considered not medically necessary.
Individual consideration will be given to cases where there is specific documentation in the patient’s medical record to perform both a transvaginal and transabdominal ultrasound on the same date of service. This documentation must include:
- The suspected condition; and
- Failure of the initial ultrasound to diagnose or confirm suspicions.
Ultrasounds in maternity care are considered not medically necessary unless billed with the appropriate CPT code (as determined by the current CPT Standard Edition) indicated for the scan. (See Key Points)
A detailed or targeted anatomic examination (76811) may be considered medically necessary only when an anomaly is suspected on the basis of history, laboratory abnormalities, or the results of either the limited or standard examination or when the mother is obese as defined by BMI of 30 or greater. (See Key Points)
Serial screening ultrasounds to assess for fetal anatomy and fetal organ development in patients at low risk for congenital abnormalities are considered not medically necessary.
Maternity ultrasounds for cervical length assessment* may be considered medically necessary when performed between 16 and 24 weeks gestation in patients with a history of cervical insufficiency (i.e. preterm birth <34 weeks or spontaneous/unexplained premature rupture of membranes <34 weeks). If the cervical length during this time is normal then ultrasounds for cervical length assessment only meet for coverage when performed at least two weeks apart.
*Maternity ultrasounds for cervical length assessment for patients with a history of or risk factors for preterm labor are considered not medically necessary.
See Policy #231 for Fetal Echography
See Policy #232 for Fetal Biophysical Profile
DESCRIPTION OF PROCEDURE OR SERVICE:
Ultrasound is the transmission of high-frequency sound waves through tissues of varying densities. Images created by the echoes of the sound waves are transmitted from a transducer to a CRT or television monitor.
Ultrasound may provide valuable information about fetal health including:
- Age of the fetus
- Rate of growth of the fetus
- Placement of the placenta
- Fetal position, movement, breathing and heart rate
- Amount of amniotic fluid in the uterus
- Number of fetuses
- Some birth defects
The most recent literature review was updated through August 11, 2021.
Per the American Medical Association Current Procedural Terminology (CPT):
Codes 76801 and 76802 include determination of the number of gestational sacs and fetuses, gestational sac/fetal measurements appropriate for gestation, survey of visible fetal and placental anatomic structure, assessment of amniotic fluid volume/gestational sac shape and examination of the maternal uterus and adnexa for fetuses younger than 14 weeks 0 days.
Codes 76805 and 76810 include determination of number of fetuses and amniotic/chorionic sacs, measurements appropriate for gestational age, survey of intracranial/spinal/abdominal anatomy, four chambered heart, umbilical cord insertion site, placenta location and amniotic fluid assessment and examination of maternal adnexa for fetuses older than or equal to 14 weeks 0 days.
Codes 76811 and 76812 include all elements of codes 76805 and 76810 plus detailed anatomic evaluation of the fetal brain/ventricles, face, heart/outflow tracts and chest anatomy, abdominal organ specific anatomy, number/length/architecture of limbs and detailed evaluation of the umbilical cord and placenta and other fetal anatomy as clinically indicated.
Report should document the results of the evaluation of each element described above or the reason for non-visualization.
Code 76815 represents a focused “quick look” exam limited to the assessment of one or more of the elements listed in the code.
Code 76816 describes and examination designed to reassess fetal size and interval growth or reevaluate one or more anatomic abnormalities of a fetus previously demonstrated on ultrasound, and should be coded once for each fetus requiring reevaluation using modifier 50 for each fetus after the first.
Code 76817 describes a transvaginal obstetric ultrasound performed separately or in addition to one of the transabdominal examinations described above.
The American College of Obstetricians and Gynecologists (ACOG) uses the terms “standard”, “limited”, and “specialized” to describe various types of ultrasound examinations performed during pregnancy.
A standard ultrasound examination includes an evaluation of fetal presentation, amniotic fluid volume, cardiac activity, placental position, fetal biometry, and fetal number, plus an anatomic survey.
A limited examination would be performed to confirm fetal heart activity in a patient experiencing vaginal bleeding or to establish fetal presentation in a laboring patient. A limited examination also may be performed in any trimester to evaluate internal growth, estimate amniotic fluid volume, evaluate the cervix, and assess the presence of cardiac activity.
A specialized examination is a detailed or targeted anatomic examination performed when an anomaly is suspected on the basis of history, laboratory abnormalities, or the result of either the limited or standard ultrasound examination.
Practice Guidelines and Position Statements
American College of Obstetrics and Gynecology
In 2018, ACOG reaffirmed Practice Bulletin No. 175 (2016)- Ultrasounds in Pregnancy. They state the following:
Essential Elements of Standard Examination of Fetal Anatomy
- Head, Face and Neck*
- Choroid plexus
- Cisterna magna
- Lateral cerebral ventricles
- Midline flax
- Cavum septi pellucidi
- Upper lip
- Chest-heart (the basic cardiac examination includes a four chamber view of the fetal heart. As part of the cardiac screening examination, an attempt should be made if technically feasible, to view the outflow tracts.)
- Stomach (presence, size, and situs)
- Umbilical cord insertion site into the fetal abdomen
- Umbilical cord vessel number
- Spine-cervical, thoracic, lumbar and sacral spine
- Extremities-legs and arms (presence or absence)
- Sex-in multiple gestations and when medically indicated in low-risk pregnancies
*A measurement of the nuchal fold may be helpful during a specific age interval to suggest an increased risk of aneuploidy.
In 2021, ACOG replaced Practice Bulletin no. 145 with no. 229 - Antepartum Fetal Surveillance. They state that “the goal of antepartum fetal surveillance is to reduce the risk of stillbirth. Antepartum fetal surveillance techniques based on assessment of fetal heart rate patterns have been used in clinical use for almost four decades and are used along with real time ultrasonography…to evaluate fetal well-being. Antepartum fetal surveillance techniques are routinely used to assess the risk of fetal death in pregnancies complicated by preexisting maternal conditions (e.g., Type 1 diabetes mellitus) as well as those in which complications have developed (e.g., intrauterine growth restriction).”
Ultrasound, sonogram, transvaginal ultrasound, transabdominal ultrasound, ultrasound screening, high-risk pregnancy, three-dimensional (3D) ultrasound, 3D ultrasound
APPROVED BY GOVERNING BODIES:
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply
FEP: Special benefit consideration may apply. Refer to member’s benefit plan. FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach; single or first gestation
; each additional gestation
Ultrasound pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation
Ultrasound pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation
; each additional gestation
Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses
Ultrasound, pregnant uterus, real time with image documentation, follow-up (e.g., re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus
Ultrasound, pregnant uterus, real time with image documentation, transvaginal
- ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologist, Antepartum fetal surveillance, No. 9, October 1999 (reaffirmed July 2014).
- ACOG Practice Bulletin. Antepartum Fetal Surveillance. No 145, July 2014 (Reaffirmed 2019).
- ACOG Practice Bulletin. Antepartum fetal surveillance. No. 229; Interim update, June 2021.
- ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologist, Gestational diabetes. No 30, September 2001.
- ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologist, Ultrasonography in pregnancy. No 101, February 2009.
- ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologist, Assessment of risk factors for preterm birth. No. 31, October 2001.
- ACOG Practice Bulletin. Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies. No 169, October 2016.
- ACOG Practice Bulletin. Prediction and Prevention of Preterm Birth. Number 130, October 2012.
- ACOG Practice Bulletin. Management of Preterm Labor. Number 159, January 2016.
- ACOG Practice Bulletin. Ultrasounds in Pregnancy. Number 175, December 2016 (Reaffirmed 2018).
- ACOG Committee Opinion. Obesity in pregnancy. Number 549; January 2013.
- AETNA, Clinical Policy Bulletins. Antepartum Fetal Surveillance. May 9, 2003.
- Alabama Perinatal Excellence Collaborative. Twin Pregnancy. June 30, 2015. Available at: apecguidelines.org/guideline/twin-pregnancy/. Accessed March 1, 2017.
- Antenatal care of low risk pregnancies: ultrasound, Clinical Evidence 2001, 5:960-971.
- American Medical Association Current Procedure Terminology (CPT). Professional Edition 2010.
- Bernaschek G., Ruaelstorfer R., Csaaicsich P. Vaginal sonography versus serum human chorionic gonadotropin in early detection of pregnancy, Am J Obstet Gynecol 1988, 158:608-612.
- Bubb JA and Matthews AL. What’s new in prenatal screening and diagnosis? Primary Care; Clinics in Office Practice 2004;31(3).
- Chasen ST, Chervenak FA. Twin pregnancy: Prenatal issues. Up to Date, Nov. 2016. Available at: www.uptodate.com/contents/twin-pregnancy-prenatal-issues?source=search_result&search=twin%20pregnancy:%20prenatal%20issues&selectedTitle=1~150. Accessed March 1, 2017.
- Dyson RL, Pretorius DH, Budorick NE, Johnson DD, Sklansky MS, Cantrell CJ, et al. Three-dimensional ultrasound in the evaluation of fetal anomalies. Ultrasound Obstet Gynecol 2000; 16:321-8.
- IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
- Johnson DD, Pretorius DH, Riccabona M, Budorick NE, Nelson TR. Three-dimensional ultrasound of the fetal spine. Obstet Gynecol 1997; 89:434-8.
- Krakow D, Williams III J, Poehl M, Rimoin DL, Platt LD. Use of three-dimensional ultrasound imaging in the diagnosis of prenatal-onset skeletal dysplasias. Ultrasound Obstet Gynecol 2003; 21:467-72.
- Lazarus E. What’s new in the first trimester ultrasound. Radiolog Clin of North Am 2003; 41(4).
- Lazebnik N, Lazebnik RS. The role of ultrasound in pregnancy-related emergencies. Radiolog Clin of North Am 2004; 42(2).
- Lee W, Kirk JS, Shaheen KW, Romero R, Hodges AN, Comstock CH. Fetal cleft lip and palate detection by three-dimensional ultrasonography. Ultrasound Obstet Gynecol 2000; 16:314-20.
- Lev-Toaff AS, Ozhan S, Pretorius D, Bega G, Kurtz AB, Kuhlman K. Three-dimensional multiplanar ultrasound for fetal gender assignment: value of the mid-sagittal plane. Ultrasound Obstet Gynecol 2000; 16:345-50.
- Mongelli M. First trimester dating by ultrasonography reduced the risk of induction of labour for postterm pregnancy. Evidence-based Obstetrics & Gynecology 2005; 7(1); 9-10.
- Moore C, Promes SB. Ultrasound in pregnancy. Emerg Med Clin of North Am 2004; 22(3).
- Pearlman M.D., Tintinalli J.E., Lorenz R.P. A prospective controlled study of outcome after trauma during pregnancy, Am J Obstet Gynecol 1990, 162:1502-1510.
- Preboth, Monica. ACOG Guidelines on Antepartum Fetal Surveillance, American family Physician, September 2000.
- Warren W.B., Timor-Tritsch I.E., Peisner D.B., Raju S., Rosen M.G. Dating the early pregnancy by sequential appearance of embryonic structures, Am J Obstet Gynecol 1989, 161:831-833.
Medical Policy Administration Committee, September 2001
MASA Third Party Task Force, September 2001
Medical Policy Group, October 2003 (1)
Available for comment August 24-October 7, 2004
Medical Policy Group, June 2005 (2)
Medical Policy Administration Committee, June 2005
Available for comment August 6-September 19, 2005
Medical Policy Group, December 2005 (2)
Medical Policy Administration Committee, December 2005
Available for comment December 27, 2005-February 9, 2006
Medical Policy Group, March 2006 (2)
Medical Policy Administration Committee, March 2006
Available for comment March 31-May 15, 2006
Medical Policy Group, August 2006 (2)
Medical Policy Administration Committee, August 2006
Available for comment August 15-September 28, 2006
Medical Policy Group, September 2007 (2)
Medical Policy Administration Committee, September 2007
Available for comment September 30-November 13, 2007
Medical Policy Group, January 2008 (2)
Medical Policy Administration Committee, February 2008
Medical Policy Group, March 2008 (2)
Medical Policy Administration Committee, April 2008
Available for comment April 4-May 18, 2008
Medical Policy Group, September 2008 (2)
Medical Policy Administration Committee, October 2008
Available for comment October 4-November 17, 2008
Medical Policy Group, January 2010 (2)
Medical Policy Group, May 2010 (2)
Medical Policy Administration Committee, May 2010
Available for comment May 26-July 9, 2010
Medical Policy Group, October 2013 (2): Removed ICD-9 Diagnosis/Procedure codes; no change to policy statement.
Medical Policy Group, April 2014 (2): Added statement to policy to cover 76811 for obese mothers (BMI of 30 or greater). Added January 2013 ACOG reference to support coverage statement to Key Points and References. Deleted policy statements prior to April 5, 2008.
Medical Policy Administration Committee, May 2014
Available for comment May 22 through July 5, 2014
Medical Policy Group, August 2016 (4): Updates to Key Points and References. Update to policy statement regarding cervical length assessment. Patients with a history of cervical insufficiency (i.e. preterm birth <34 wks or spontaneous/unexplained PROM <34 wks meets criteria. Removed policy statements for effective dates of service between November 1, 2001 through July 9, 2010.
Medical Policy Administration Committee, September 2016
Available for comment August 23 through October 6, 2016
Medical Policy Group, March 2017 (4): Update to References and policy statement, adding specific criteria for monochorionic and dichorionic twins regarding ultrasounds.
Medical Policy Administration Committee, March 2017
Medical Policy Group, January 2020 (4): Removed policy statements effective for dates of services on or after July 6, 2014 and prior to August 22, 2016.No other changes to policy statements. Updates to Key Points and References.
Medical Policy Group, August 2021 (4): Updates to Policy, Key Points, and References. Policy statement updated to remove “investigational,” no change to policy intent. Removed statement: Patients will be held harmless for these ultrasounds unless a waiver is signed by the patient for a specific ultrasound on a specific date.Removed policy statements effective for dates of service August 22, 2016 and prior to March 1, 2017.
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.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
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
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent
therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.