Medical Policy
Effective Date:09/18/1995 Title:Fetal Surgery in Utero
Revision Date:10/01/2015 Document:BI115:00
CPT Code(s):59070, 59072, 59074, 59076, 59897
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Surgical procedures on the unborn fetus are high profile interventions, but have mostly not been shown to be scientifically supportable. Most such procedures are still considered by QualChoice to be experimental or investigational.

Medical Statement
  1. In utero fetal surgery is considered medically necessary for any of the following indications:
    • Amnioinfusion (59070) as treatment of oligohydramnios (P01.2);
    • Vesico-amniotic shunting (59076) as a treatment of urinary tract obstruction (Q64.31-Q64.39);
    • In utero resection of malformed pulmonary tissue (59897), or placement of a thoraco-amniotic shunt (59076) as a treatment of either of the following:
      • congenital cystic adenomatoid malformation (Q89.9); or
      • extra lobar pulmonary sequestration (Q33.2 - Q33.3, Q33.6);
    • In utero removal of sacro-coccygeal teratoma (59897) (O33.7).
  2. QualChoice considers the following applications of in utero fetal surgery experimental and investigative:
    • Laser ablation of anastomotic vessels (59897) in twin-twin transfusion  syndrome (O43.021-O43.029);
    • In utero repair of neural tube defects (59897) for spinabifida (O35.0XX1 -  O35.0XX9); Fetal tracheal occlusion (59897) for congenital diaphragmatic hernia (Q79.0)
    • Surgical repair of diaphragmatic hernia (Q79.0, Q79.1).
  3. QualChoice considers other applications of in utero surgery experimental and investigative.

 

Codes Used In This BI:

 

59070 Transabdom Amnioinfus w/US

59072 Umbilical Cord Occlude w/US

59074 Fetal Fluid Drainage w/US

59076 Fetal Shunt Placement w/US

59897 Fetal Invas PX w/US
Limits
Intentially left empty
Reference
  1. Scott JR, Di Saia PJ, Hammond CB, et al, eds. Danforth`s Obstetrics and Gynecology. Philadelphia, PA: Lippincott Williams & Wilkins;1999:228-230.
  2. Adzick NS, Sutton LN, Cromblehome TM, et al. Successful fetal surgery for spina bifida. Lancet. 1998;352:1675-1676.
  3. Quintero RA, Bornick PW, Allen MH, Johnson PK. Selective laser photocoagulation of communicating vessels in severe twin-twin transfusion syndrome in women with an anterior placenta. 2001;97(3):477-481.
  4. Odibo AO, Macones GA. Management of twin-twin transfusion syndrome: Laying the foundation for future interventional studies. Twin Res. 2002;5(6):515-520.
  5. Ropacka M, Markwitz W, Blickstein I. Treatment options for the twin-twin transfusion syndrome: A review. Twin Res. 2002;5(6):507-514.
  6. Evans MI, Harrison MR, Flake AW, Johnson MP. Fetal therapy. Best Pract Res Clin Obstet Gynaecol. 2002;16(5):671-683.
  7. Coleman BG, Adzick NS, Crombleholme TM, et al. Fetal therapy: State of the art. J Ultrasound Med. 2002;21(11):1257-1288.
  8. Quintero RA, Martinez JM, Bermudez C, et al. Fetoscopic demonstration of perimortem feto-fetal hemorrhage in twin-twin transfusion syndrome. Ultrasound Obstet Gynecol. 2002;20(6):638-639.
  9. Quintero RA, Dickinson JA, Morales WJ, et al. Stage-based treatment of twin-twin transfusion syndrome. Am J Obstet Gynecol. 2003;188(5):1333-1340.
  10. Tsao K, Albanese CT, Harrison MR. Prenatal therapy for thoracic and mediastinal lesions. World J Surg. 2003;27(1):77-83.
  11. Martinez JM, Bermudez C, Becerra C, et al. The role of Doppler studies in predicting individual intrauterine fetal demise after laser therapy for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol. 2003;22(3):246-251.
  12. Walsh DS, Adzick NS. Fetal surgery for spina bifida. Semin Neonatal. 2003;8(3):197-205.
  13. Adzick NS, Kitano Y. Fetal surgery for lung lesions, congenital diaphragmatic hernia, and sacro-coccygeal teratoma. Semin Pediatric Surg. 2003;12(3):154-167.
  14. Sydorak RM, Harrison MR. Congenital diaphragmatic hernia: Advances in prenatal therapy. Clin Perinatal. 2003;30(3):465-479.
  15. Au-Yeung JY, Chan KL. Prenatal surgery for congenital diaphragmatic hernia. Asian J Surg. 2003;26(4):240-243.
  16. Downard CD, Wilson JM. Current therapy of infants with congenital diaphragmatic hernia. Semin Neonatal. 2003;8(3):215-221.
  17. Harrison MR, Keller RL, Hawgood SB, et al. A randomized trial of fetal endoscopic tracheal occlusion for severe fetal congenital diaphragmatic hernia. N Engl J Med. 2003;349(20):1916-1924.
  18. Heerema AE, Rabban JT, Sydorak RM, et al. Lung pathology in patients with congenital diaphragmatic hernia treated with fetal surgical intervention, including tracheal occlusion. Pediatric Dev Pathol. 2003 Nov 5 [Epub ahead of print]
  19. Wenstrom KD. Fetal surgery for congenital diaphragmatic hernia. N Engl J Med. 2003;349(20):1887-1888.
  20. Ruano R, Yoshisake CT, da Silva MM, et al.  A randomized controlled trial of fetal endoscopic tracheal occlusion versus postnatal management of severe isolated congenital diaphragmatic hernia.  Ultrasound Obstet Gynecol. 2012;39(1):20-27
  21. Ruano R, da Silva MM, Campos JA, et al.  Fetal pulmonary response after fetoscopic tracheal occlusion for severe isolated congenital diaphragmatic hernia.

Obstet Gynecol. 2012a;119(1):93-101.

  1. Hayes Medical Technology Report.  In Utero Fetal Surgery for Congenital Diaphragmatic Hernia.  Published October 23, 2012, accessed October 29, 2012.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.