Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 09/18/1995 Title: Abortion
Revision Date: 11/01/2014 Document: BI206:00
CPT Code(s): 59840, 59841, 59850-59852, 59855-59857, 59866
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.

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.


Medical Statement

 

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:

59840

Abortion

59841

Abortion

59850

Abortion

59851

Abortion

59852

Abortion

59855

Abortion

59856

Abortion

59857

Abortion

59866

Abortion (mpr)


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.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.