Latest Review Date: February 2024

Category: Obstetrics                                                              

POLICY:

For dates of service August 1, 2023, and after:

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 increased 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
  • Pregnancy conceived with in vitro fertilization

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 than every seven days.   

Effective for Dates of service prior to August 1, 2023:

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 increased 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 than every seven days.  

DESCRIPTION OF PROCEDURE OR SERVICE:

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.

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).

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 outcomes and small-for-gestational-age infants.

KEY POINTS:

A literature review was conducted through February 8, 2024.

Summary of Evidence

There 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 of 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. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

U.S. Preventive Services Task Force

Not applicable

Practice Guidelines and Position Statements

The American College of Obstetricians and Gynecologists

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

In 2021, ACOG updated Practice Bulletin 229 regarding antepartum fetal surveillance.

• “In growth-restricted 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 a modified BPP generally should be 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 high-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:  Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING: 

CPT codes:

REFERENCES:

1. American College of Obstetricians and Gynecologists. Committee Opinion: Indications for outpatient antenatal fetal surveillance. Number 828, June 2021.
2. American College of Obstetricians and Gynecologists. Practice Bulletin: Antepartum fetal surveillance. Number 145, July 2014.
3. American College of Obstetricians and Gynecologists. Practice Bulletin: Ultrasound in Pregnancy. Number 175, December 2016.
4. American College of Obstetricians and Gynecologists. Practice Bulletin: Antepartum Fetal Surveillance. Number 229, June 2021.
5. American College of Obstetricians and Gynecologists. Special tests for monitoring fetal well-being. FAQs. Available at: https://www.acog.org/womens-health/faqs/special-tests-for-monitoring-fetal-well-being
6. American College of Radiology. ACR appropriateness criteria. Growth disturbances-risk of fetal growth restriction. https://acsearch.acr.org/docs/69377/Narrative/. Accessed February 19, 2021.
7. Booker W, Fox NS, Gupta S, et al. Antenatal Surveillance in Twin Pregnancies using the Biophysical Profile. J Ultrasound Med. 2015 Nov;34(11):2071-5.
8. Gardner MO and Doyle NM.  Asthma in pregnancy.  Obstet Gynecol Clin North Am 2004;31(2):385-413.
9. Kontopoulos EV and Vintzileos AM.  Condition-specific antepartum fetal testing. Am J Obstet Gynecol 2004; 191(5): 1546-51.
10. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
11. Lewis DF, Adair CD, et al.  A randomized clinical trial of daily non-stress testing versus biophysical profile in the management of preterm premature rupture of membranes.  Am J Obstet Gynecol 1999; 181(6).   
12. Manandhar BL, Giri K, Rana A. Fetal biophysical profile score and perinatal outcome. J Nepal Health Res Counc. 2013 Sep; 11(25):269-72.
13. 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.
14. Neff MJ.  ACOG releases guidelines on management of post-term pregnancy.  Am Fam Physician 2004; 70(11): 2221-25.
15. 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.
16. Panting-Kemp A, Nguyen T, Castro L.  Substance abuse and polyhydramnios.  Am J Obstet Gynecol 2002; 187(3).
17. Rakel: Textbook of Family Practice, 6th ed.  2002 W.B. Saunders Company.
18. Schroeder BM.  ACOG practice bulletin on thyroid disease in pregnancy.  Am Fam Physician 2002; 65(10): 2158, 2161-62.
19. Schroeder BM.  ACOG practice bulletin on diagnosing and managing preeclampsia and eclampsia.  Am Fam Physician 2002; 66(2): 330-31.
20. 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.

Medical Policy Group, February 2021 (4): Updates to Description, Key Points, and References.  No change to policy statement.

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

Medical Policy Group, February 2023 (4): Reviewed by consensus.  No new published peer-reviewed literature available would alter the coverage statement in this policy.

Medical Policy Group, August 2023 (4): Update to policy statement and References.  Added in vitro fertilization to covered indications in policy statement.   

Medical Policy Administration Committee: July 2023

Available for Comment: August 1 – September 15, 2023

Medical Policy Group, February 2024 (4): Updates to Key Points and Benefit Application.  No change to policy statements. 

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.