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.

1)    Elective termination of pregnancy is not a covered service.

2)    Therapeutic termination of pregnancy requires preauthorization, and will only be authorized if the mother’s life is endangered by continuation of the pregnancy. Documentation of concurrence of two additional network physicians that the mother’s life is endangered is required.

3)    Any costs entailed in the performance of or in complications arising from any non-covered termination of pregnancy are not covered.

1)    Elective termination of pregnancy is not covered.

2)    Therapeutic termination of pregnancy is covered, with preauthorization, only when determined to be Medically Necessary because the mother’s life is endangered by continuation of the pregnancy (the surgeon who would be performing the procedure should request the pre-authorization with documentation of second opinions from two independently practicing physicians who can speak to the risk posed to the mother’s life from continuation of the pregnancy).

3)    Associated anesthesia and facility charges (if any) and the care of complications caused by any non-covered termination of pregnancy are also not covered.

4)    The following are examples of conditions where the life of the mother could be endangered if the fetus was carried to term:

a)    Severe psychiatric impairment (as evidenced by prior institutionalization or prior suicidal attempts)

b)    Severe cardiac disease (prior history of cardiac decompensation)

c)    Cancer (carcinoma of the cervix, breast, or uterus)

d)    Advanced hypertensive cardiovascular disease

e)    Severe renal disease (on renal dialysis, severe renal impairment due to either chronic or acute kidney disease)

f)     Intracranial aneurysms (history of prior intracranial bleeding)

g)    History of repeated and severe postpartum hemorrhage with prior pregnancies

h)   Severe diabetes

i)     Blood clotting abnormality resulting in a high risk of bleeding or clotting.

Codes Used In This BI: