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)    Up to three (3) fetal survey ultrasounds will be covered without prior authorization. Additional ultrasound examinations will require demonstration that all ultrasounds performed were specifically medically indicated.

2)    Doppler velocimetry, fetal echocardiography, and fetal Doppler echocardiography require preauthorization. For fetal genetic testing, please see BI205.

1)    Up to three (3) Level 1 fetal ultrasounds will be covered per pregnancy without preauthorization. More than three (3) Level 1 fetal ultrasounds per pregnancy will require preauthorization.

2)    All other fetal ultrasounds, including fetal echocardiography, Doppler velocimetry, and biophysical profiles, require provision of medical records to demonstrate specific medical necessity for each ultrasound performed.

Fetal echocardiography, fetal Doppler echocardiography and Doppler velocimetry require preauthorization.

3)    A Level 2 ultrasound will be covered between 16–22 weeks for:

a)    Women of advanced maternal age (over 35); or

b)    Women with personal history of, or a first degree relative with a history of, babies with congenital birth defects;

c)    Women with known or suspected exposure to teratogens;

d)    Women with preexisting or gestational diabetes;

e)    Suspected anomaly on the basis of history or laboratory abnormalities.

4)    For fetal genetic testing, see BI205.

5)    For women with diabetes, the following ultrasounds are indicated:

a)    First trimester scan for viability and accurate dating;

b)    Level two ultrasound between 16–22 weeks gestation

i)   For women determined at a later date to be gestational diabetics, a level two ultrasound will be approved even if a previous routine scan has been performed;

c)    Fetal echocardiography between 20–24 weeks gestation

i)   For women determined at a later date to be gestational diabetics, fetal echocardiography will be approved;

d)    Serial fetal growth assessments during the third trimester if clinically indicated. Such indications include previous macrosomia or IUFD, excessive fetal growth as documented by fundal measurements, or poor glucose control.

6)    For women with known multiple gestation the following ultrasounds are indicated:

a)    First trimester screening scan (typically at 11–14 weeks) to evaluate anatomy and chronicity;

b)    Level 2 ultrasound between 16–22 weeks;

c)    Ultrasound to monitor growth every 4–6 weeks after 22 weeks

i)   If discordant growth or IUGR is discovered, more frequent scans may be necessary;

ii)  For monochorionic twins, ultrasound every 2–3 weeks beginning at 24 weeks.

7)    Additional Level 1 ultrasounds are covered when one of the following is present and the result of the exam will directly impact the care of the patient:

a)    History of prior high risk pregnancy or obstetrical complications; or

b)    Presence of high risk factors (e.g., maternal diabetes, malnutrition or drug addiction); or

c)    Uncertain gestational age in third trimester; or

d)    IUGR (serial exams will be covered every 2–4 weeks); or

e)    Suspected abnormalities of pregnancy, as listed in the table below:

8)    Level 2 ultrasound examinations are covered as outlined below:

a)    When fetal abnormalities are suspected after other obstetrical ultrasounds;

b)    For suspected toxoplasmosis;

c)    When IUGR is suspected on the basis of discrepancy between fetal size and estimated age.

9)    Fetal echocardiography is covered with preauthorization for any one of the following:

a)    A Level 2 ultrasound is suspicious for cardiac anomaly or when other fetal cardiac

disease is suspected. 

Familial Indications

·      Maternal history of a congenital heart defect (CHD)

·      Maternal autoimmune conditions with antibodies affecting the fetus (i.e., Lupus, Sjögren’s syndrome)

·      Maternal metabolic conditions with potential to affect cardiac development (i.e., Diabetes, Phenylketonuria [PKU])

·      Maternal exposure to teratogenic substances (i.e., medications, drugs, solvents or known environmental risk factors)

·      Maternal viral infections during pregnancy with potential to have cardiac effects (i.e., parvo, coxsackie, cytomegalovirus, rubella)

·      Pregnancies conceived with ART/IVF (assisted reproductive technology/ in-vitro fertilization)

·      Paternal history of congenital heart defect

o   First-degree relatives with congenital heart defects

·      Syndromes with Mendelian inheritance associated with congenital heart disease (i.e., Marfan, DiGeorge,Williams, Noonan, Holt-Oram, Ellis-van Crevald, familial cardiomyopathies

Fetal Indications

·      Abnormal Appearing Fetal Heart (i.e., structure, position or axis)

·      Fetal Cardiac Arrhythmias

·      Fetal Hydrops

·      Situations with Increased Fetal Cardiac Output

o   Arterio-venous malformations

o   Teratomas

o   Twin-twin transfusion

o   Twin reversed arterial perfusion (TRAP)

o   Disease processes causing fetal anemia

·      Suspected or Confirmed Abnormal Fetal Karyotype

·      Extracardiac Fetal Disease or Extracardiac Fetal Abnormality

·      CNS Abnormalities

o   Hydrocephalus

o   Dandy-Walker malformation

o   Agenesis of the corpus callosum

·      Mid-line Defect

o   Cleft lip/palate

·      Thoracic Abnormalities

o   Diaphragmatic hernia

o   Tracheo-esophageal fistulae

·      GI Abnormalities

o   Esophageal, duodenal or other suspected bowel atresia’s

o   Omphaloceles

o   Gastroschisis

·      Renal and Genitourinary Anomalies

·      Two-vessel Umbilical Cord

·      Increased Nuchal Lucency between 10–14 weeks gestation

10)   Serial fetal echocardiography may be covered in selected cases.

11)   In pregnancies with established IUGR, Doppler velocimetry will be covered weekly with preauthorization as part of fetal monitoring.

12)   Fetal biophysical profiles, with or without non-stress testing, will be covered when required to monitor at-risk fetuses.

Codes Used In This BI:

1.     Ultrasounds are not considered medically necessary if done solely to determine the fetal sex, or to provide parents with a view and photograph of the fetus.

2.     Ultrasounds are not considered medically necessary if done solely to determine dating in the first trimester.

3.     More than one detailed (level two) fetal anatomic examination per practice per pregnancy is considered experimental and investigational, as there is inadequate evidence to determine the clinical utility of repeated detailed ultrasound in pregnancy.

4.     3D and 4D ultrasounds are considered experimental/ investigational as there is insufficient peer reviewed studies to demonstrate effectiveness.

1)    Ji EK, Pretorius DH, Newton R, et al. Effects of ultrasound on maternal-fetal bonding: A comparison of two- and three-dimensional imaging. Ultrasound Obstet Gynecol. 2005; 25(5):473-477.

2)    Benacerraf BR, Shipp TD, Bromley D. How sonographic tomography will change the face of obstetric sonography: A pilot study. J Ultrasound Med. 2005; 24(3):371-378.

3)    Benacerraf BR, Shipp TD, Bromley B. Improving the efficiency of gynecologic sonography with 3-dimensional volumes: A pilot study. J Ultrasound Med. 2006; 25(2):165-171.

4)    Benacerraf BR, Shipp TD, Bromley B.  Three-dimensional US of the fetus: Volume imaging. Radiology. 2006; 238(3):988-996.

5)    American College of Obstetricians and Gynecologists (ACOG) Committee on Health Care for under deserved Women; ACOG Committee on Obstetric Practice. ACOG committee opinion. Number 316, October 2005. Smoking cessation during pregnancy. Obstet Gynecol. 2005; 106(4):883-888.

6)    American College of Obstetricians and Gynecologists (ACOG), Committee on Practice Bulletins -- Obstetrics. Ultrasonography in pregnancy. ACOG Practice Bulletin No. 98. Washington, DC: ACOG; October 2008.

7)    Clinical Practice Obstetrics Committee; Maternal Fetal Medicine Committee, Delaney M, Roggensack A, Leduc DC, et al. Guidelines for the management of pregnancy at 41+0 to 42+0 weeks. J Obstet Gynaecol Can. 2008; 30(9):800-823.

8)    Chen M, Lee CP, Lam YH, et al. Comparison of nuchal and detailed morphology ultrasound examinations in early pregnancy for fetal structural abnormality screening: A randomized controlled trial. Ultrasound Obstet Gynecol. 2008; 31(2):136-146; discussion 146.

9)    American College of Obstetricians and Gynecologists (ACOG), Committee on Practice Bulletins -- Obstetrics. Ultrasonography in pregnancy. ACOG Practice Bulletin No. 101. Washington, DC: ACOG; February 2009.

10)     ACOG Committee on Practice Bulletins -- Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2008; 111(4):1001-1020.

11)     Yagel S, Cohen SM, Messing B, Valsky DV. Three-dimensional and four-dimensional ultrasound applications in fetal medicine. Curr Opin Obstet Gynecol. 2009; 21(2):167-174.

12)     Chen M, Wang HF, Leung TY, et al. First trimester measurements of nasal bone length using three-dimensional ultrasound. Prenat Diagn. 2009; 29(8):766-770.

13)     Kurjak A, Abo-Yaqoub S, Stanojevic M, et al. The potential of 4D sonography in the assessment of fetal neurobehavior -- multicentric study in high-risk pregnancies. J Perinat Med. 2010; 38(1):77-82.

14)     Pasquini L, Wimalasundera RC, Fisk NM. Management of other complications specific to monochorionic twin pregnancies.  Best Pract Res Clin Obstet Gynaecol. 2004; 18(4): 577-599.

15)     Roque H, et al. Perinatal outcomes in monoamniotic gestations. J Matern Fetal Neonatal Med. 2003;13(6):414-421

16)     ACOG. Practice Bulletin #56: Multiple gestation: complicated twin, triplet, and high-order multiple pregnancy.  Obstet Gynecol. 2004;104(4):869:883 (Reaffirmed 2009)

17)     Cunningham FG, et al. Multifetal pregnancy. In Williams Obstetrics (23rd ed.) (pp. 859-889) (2010)

18)     Kjos SL, et al. Antepartum surveillance in diabetic pregnancies: predictors of fetal distress in labor. Am J OBstet Gynecol. 1995;173(5):1532-1539

19)     Dicker d, et al. Fetal surveillance in insulin-dependent pregnancy: predictive values of the biophysical profile. Am J Obstet Gynecol. 1998;159(4):800-804

20)     Friedberg MK, Silverman NH. Changing indications for fetal echocardiography in a University Center population.  Prenat Diagn. 2004;24(10):781-786

21)     American Diabetes Association. (2004). Gestational diabetes mellitus. Retrieved June 30, 2004, from the National Guideline Clearinghouse at http://www.guideline.gov.

22)     American College of Obstetricians and Gynecologists, ACOG Committee on Practice Bulletins (with Gabbe, S.G.). (2005). Pregestational diabetes mellitus. ACOG Practice Bulletin No. 60.

23)     American College of Obstetricians and Gynecologists, ACOG Committee on Practice Bulletins (with Rouse, D.J.). (1999 Reaffirmed 2009). Antepartum fetal surveillance. ACOG Practice Bulletin No. 9.

24)     Resnik, R. (2009, March). Fetal Growth Restriction: Evaluation and Management. Up-to-date Online. Retrieved September 4, 2010 from http://www.utdol.com.

25)     American College of Obstetricians and Gynecologists, Committee on Educational Bulletins of the American College of Obstetricians and Gynecologists. (Reaffirmed 2008). Intrauterine growth restriction. ACOG Educational Bulletin No. 12. In 2003 Compendium of selected publications (pp.384-395).

26)     American College of Radiology (ACR), Expert Panel on Women’s Imaging. (2001). Growth disturbances: Risk of intrauterine growth restriction. Retrieved September 29,2003 from http://www.acr.org/s_acr/bin.asp?TrackID=&SID=1&DID=11859&CID=1201&VID=2&DOC=File .PDF

27)     Leeman L, Fontaine P. Hypertensive disorders of pregnancy. American Family Physician 2008;78(1):93-100

This policy applies to all health plans and products 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) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.