Latest Review Date: April 2024

Category: OB\GYN                                                   

POLICY

Hyperemesis Management:

Hyperemesis management may be considered medically necessary when coordinated by an Obstetrical Care Coordinator when the patient meets the following criteria:

• Documented weight loss
• Documented failure of oral antiemetics

The following treatments can be provided in the patient’s home:

• Home Intravenous Fluid Hydration
• IV Antiemetics
• SQ Reglan Pump
• SQ Zofran Pump

Anti-coagulant Therapy:

Subcutaneous heparin therapy may be considered medically necessary for treatment of active DVT when coordinated by an Obstetrical Care Coordinator.

Pregnancy-Induced Hypertension Management Program:

Pregnancy-Induced Hypertension Management Program may be considered medically necessary when coordinated by an Obstetrical Care Coordinator when the patient is on bedrest and meets the following criteria:

• Elevated or unstable blood pressure – increased BP 15mmhg over baseline diastolic
• Proteinuria
• Fluid retention/edema
• Weight gain
• Headache

Premature Prolonged Rupture of Membrane Program (PPROM):

Premature Prolonged Rupture of Membrane Program may be considered medically necessary when coordinated by an Obstetrical Care Coordinator when the patient meets the following criteria:

• Documented rupture of membranes prior to 37 weeks gestation
• Documented amniotic fluid volume
• No signs or symptoms of infection
• Singleton gestation
• Cervix < or = to 2cm dilation
• Suitable home environment
• Appropriate presenting part of fetus

Home Uterine Activity Monitoring (HUAM):

Home uterine activity monitoring (HUAM) may be considered medically necessary with initiation of services at 24-36 weeks gestation, and is covered 36-37 weeks when coordinated by an Obstetrical Care Coordinator when the patient is on bedrest and meets the following criteria:

• Current preterm labor as documented by cervical change; OR
• Patient is experiencing increased uterine activity that is not perceived, with or without cervical change; OR
• Triplets, quads, etc. (>20 weeks gestation); OR
• History of preterm delivery due to incompetent cervix, anomalous uterus, or DES exposure; OR 
• History of 2 preterm deliveries; OR
• Cervical cerclage placed during the current pregnancy

Each case is reviewed individually per an Obstetrical Care Coordinator and may be referred to a physician advisor when the stated criteria does not apply or is not met.

DESCRIPTION OF PROCEDURE OR SERVICE

Antepartum complications can compromise the mother and fetus.  Maternal-fetal evaluation, early identification of problems, and ongoing care can contribute to an optimal birth process.  Complications frequently seen in the antepartum period are:

• Hyperemesis gravidarum (nausea and vomiting during pregnancy, NVP)
• Thromboembolitic disease (DVT)
• Pregnancy-induced hypertension (PIH)
• Premature rupture of membranes (PPROM)
• Preterm labor (PTL)

KEY POINTS

The most recent literature update was performed through April 3, 2024.

Summary of Evidence

For individuals who receive home care for conditions mentioned above such as hyperemesis and premature rupture of membranes, the evidence includes systematic reviews, retrospective studies, and controlled trials. Historically, patients were hospitalized for complications such as preterm labor, hyperemesis, and PROM, dependent upon their severity.  Advances in technology and medication use have allowed a decrease of inpatient days and continuation of care in the home setting.  Durable medical equipment (DME) can be combined with home nursing care and pharmacy services to provide patient care in the home setting and to report the patient’s health status to the physician. Most studies show that satisfaction and comfort were higher in those who received home care. Home care management has been shown to safe, efficacious and have high satisfaction rates. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

American college of Obstetrics and Gynecology

In January 2018, ACOG published Practice Bulletin No. 189 – Nausea and Vomiting of Pregnancy.  They do not have specific recommendations related to home care, but they state the following:

“After the patient has been hospitalized and a workup for other causes of severe vomiting has been undertaken, intravenous hydration, nutritional support, and modification of antiemetic therapy often can be accomplished at home.  Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in mental status, continue to lose weight and are refractory to treatment.”

U.S. Preventive Services Task Force Recommendations

Not applicable

KEY WORDS

Home uterine activity monitor (HUAM), preterm labor (PTL), tocolytic therapy, hyperemesis, vomiting during pregnancy, preeclampsia, Pregnancy Induced Hypertension Management Program, Premature Prolonged Rupture of Membrane Program, PPROM

APPROVED BY GOVERNING BODIES

Healthdyne™ System 37 Home Uterine Activity Monitoring System and the Genesis™ Home Uterine Activity Monitoring System are two devices that have received FDA approval for detecting the onset of preterm labor.

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: Special benefit consideration may apply.  Refer to member’s benefit plan.

CODING 

CPT:  

HCPCS:

REFERENCES

1. ACOG Practice Bulletin. Nausea and Vomiting of Pregnancy. No. 189; January 2018.
2. Brown HL, et al.  A randomized comparison of home uterine activity monitoring in the outpatient management of women treated for preterm labor, American Journal of Obstetrics and Gynecology, April 1999; 180(4): 798-805.
3. CHUMS Group.  A multicenter randomized controlled trial of home uterine monitoring:  Active versus sham device.  The Collaborative Home Uterine Monitoring Study (CHUMS) Group, American Journal of Obstetrics and Gynecology, October 1995; 173(4): 1120-1127.
4. Colton T, et al.  A meta analysis of home uterine activity monitoring, American Journal of Obstetrics and Gynecology, November 1995; 173(5): 1499-1505.
5. Devoe LD, et al.  Home uterine activity monitoring :  A critical review, Clinical Obstetrics and Gynecology, December 2000; 43(4): 778-786.
6. Dyson DC, et al.  Monitoring women at risk for preterm labor, The New England Journal of Medicine, January 1998, Vol. 338, pp. 15-19.
7. Goldenberg RL.  The management of preterm labor, Obstetrics and Gynecology, November 2002; 100(5 Pt. 1): 1020-1037.
8. Home Uterine Activity Monitoring:  A Guide to Clinical Preventive Services, 2nd Edition.  U.S. Preventive Services Task Force, Washington, DC, 1996.
9. Iams JD.  Prediction and early detection of preterm labor, Obstetrics and Gynecology, February 2003; 101(2): 402-412.
10. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
11. Keirse MJ, et al.  Reanalysis of a multireported trial on home uterine activity monitoring, Birth, September 1993; 20(3): 117-122.
12. Kempe A.  Home uterine activity monitoring in the prevention of very low birth weight, Public Health Rep, Sept-Oct 1997; 112(5): 433-439.
13. Maxwell CV, et al.  Alternative approaches to preterm labor, Seminars in Perinatology, October 2001; 25(5): 310-315.
14. U. S. Food and Drug Administration.  FDA drug safety communication: New warnings against use of terbutaline to treat preterm labor. February 17, 2011. www.fda.gov/drugs/drugsafety/ucm243539.htm. Last accessed October 2013.
15. U.S. Food and Drug Administration.  Medical devices; Reclassification and codification of home uterine activity monitor, Food and Drug Administration Department of Health and Human Services Final Rule, Federal Register, March 2001, Vol. 66, No. 47, pp. 14074-14076.
16. U. S. Food and Drug Administration.  Reglan Injection Drug Description.  www.rxlist.com/reglan_injection-drug.htm

POLICY HISTORY

Medical Policy Group, March 2007

Medical Policy Administration Committee, April 2007

Available for comment April 13-May 27, 2007

Medical Policy Group, March 2010 (1): Consulted with Obstetrical Care Coordinators, implemented recommended changes

Medical Policy Administration Committee, April 2010

Available for comment April 8-May 23, 2010

Medical Policy Group April 2011; Added Effective Date to T-Pump and reference to Policy #471

Available for comment April 25 – June 13, 2011

Medical Policy Group September 2011 (3): Added black box warning for Reglan and deleted requirement that Reglan pump be used prior to Zofran pump

Medical Policy Administration Committee, September 2011

Available for comment September 22 through November 7, 2011

Medical Policy Group, March 2014 (3):  Updated Description, Policy Statement & References; policy statement updated to remove “Patient is on Terbutaline subcutaneous infusion pump and home uterine monitoring” . Policy will no longer be reviewed for regular updates.

Medical Policy Group, April 2020 (4): Updates to Description and Key Points.  No change to policy statements.

Medical Policy Group, April 2021 (4): Updates to Key Points and References.  No change to policy statements.

Medical Policy Group, April 2022 (4): Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, April 2023 (4): Reviewed by consensus.  No new published peer-reviewed literature available that would alter the coverage statement in this policy.  Removed continuous anticoagulant criteria in policy section d/t IV heparin not routinely given in home setting. Added Key Words hyperemesis, vomiting during pregnancy, preeclampsia, Pregnancy Induced Hypertension Management Program, Premature Prolonged Rupture of Membrane Program, PPROM.

Medical Policy Group, April 2024 (4): Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy. Updates to Key Points and References. Clarified policy statement related to Home Uterine Monitoring by adding ORs at the end of each bullet.  Added CPT code 99500 to Current Coding.

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.