Clinical UM Guideline

Subject: Guideline #: Status: Ultrasound in Maternity Care in the Outpatient Setting CG-RAD-04 Current Effective Date: Reviewed (Coding updated 10/01/2008) Last Review Date:

01/28/2008 11/29/2007

Description
Ultrasound imaging, also called ultrasound scanning or sonography, is a method of obtaining images of internal organs by sending high-frequency sound waves into the body. The sound wave echoes are recorded and displayed as a real-time visual image. No ionizing radiation (x-ray) is involved in ultrasound imaging. Obstetric ultrasound refers to the specialized use of sound waves to visualize and determine the condition of a pregnant woman and the fetus. Ultrasound during pregnancy is used to assess the uterus, umbilical cord and placenta, as well as fetal anatomy and well being. Ultrasound imaging can be used after delivery to evaluate abnormalities of the reproductive and adjacent structures. Please see the following related document(s) for additional information: RAD.00038 Use of 3-D and 4-D Ultrasound in Maternity Care CG-RAD-20 First Trimester Detection of Down Syndrome Using Fetal Ultrasound Assessment of Nuchal Translucency Combined with Maternal Serum Assessment

Clinical Indications
Medically Necessary: Ultrasound in maternity care is considered medically necessary for: Routine anatomy screen and dating: - One ultrasound of a pregnant uterus per member, per routine course of care is considered medically necessary. Per the American College of Obstetricians and Gynecologists (ACOG), in the absence of specific indications for a first-trimester examination (1-12 weeks), the optimal timing for a single ultrasound examination is at 1620 weeks of gestation (the middle of the second trimester, 13-26 weeks). This ultrasound is used to confirm the site of the pregnancy within the uterus and evaluate fetal status; - Estimate gestational age for women with uncertain clinical dates. Known or suspected abnormality of maternal reproductive structure: - Clinical suspicion of incompetent cervix (e.g., abnormal cervix on physical examination, maternal history of second trimester pregnancy loss, prior cervical surgery, and DES exposure); - To assess cervical length in the second or third trimester in women with a history of one or more pregnancy losses in the second or early third trimester or in women who have had preterm labor in the current pregnancy or in multi-fetal pregnancies of 3 or more; - Provide guidance for cervical cerclage placement; - Confirm suspected anatomical uterine abnormality, including fibroid uterus; - Localization of intrauterine device (IUD);
Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Coverage Guidelines take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The members contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. CPT Only American Medical Association Page 1 of 6

Clinical UM Guideline
Ultrasound in Maternity Care in the Outpatient Setting
Evaluate a pelvic mass that has been detected clinically.

CG-RAD-04

Known or suspected abnormality of fetus: - Assess significant discrepancy between uterine size and dates; - Follow-up for observation of identified fetal or cord anomaly; - Evaluate suspected fetal growth abnormality (either growth restriction or macrosomia), and to follow proven or suspected intrauterine growth restriction; - Confirm suspected and/or follow confirmed diagnosis of polyhydramnios or oligohydramnios; - Estimate fetal weight and/or presentation in premature rupture of membranes and/or preterm labor; - Confirm suspected multiple gestation; - Serial evaluation of fetal growth in multi-fetal pregnancy. The most relevant clinical information is obtained when serial exams are done at least three weeks apart, beginning no earlier than 18 weeks gestation. In the case of monochorionic twins, one scan per two weeks in the third trimester is considered medically necessary; - For twin-twin transfusion syndrome, one scan per week and serial exams, more than once per week, beginning once the diagnosis of monochorionic twins or twin-twin transfusion is made; - Confirm suspected abnormal fetal position or presentation; - As an adjunct to external version from breech to vertex presentation. Known or suspected abnormality of placenta: - Assess placental location associated with vaginal bleeding; - Suspected abruptio placenta; - Follow-up of subchorionic hematoma; - Suspected abnormal placental attachment (placenta accreta); - Suspected retained placenta/products of conception. Fetal viability/well-being: - Evaluate for threatened, incomplete, or missed abortion; - Evaluation of decreased fetal movement; - Non-reassuring fetal heart rate monitoring; - Suspected fetal death; - Assess amniotic fluid volume in post-term gestation. Other high risk conditions: - Assess vaginal bleeding of undetermined etiology; - History of unexplained fetal demise in a previous pregnancy; - Assess the fetus in cases with maternal risk factors such as family history of congenital abnormalities, chronic systemic disease (including but not limited to, hypertension, diabetes, sickle cell disease preeclampsia), substance abuse, or hyperemesis gravidarum; - Assessment of fetus after abnormal serum Alpha Fetal Protein (AFP), serum screen or multiple analyte serum screen; - Suspected ectopic pregnancy or hydatidiform mole, and to follow hydatidiform mole; - Assess the fetus in cases of Rhesus (Rh) isoimmunization and other causes of fetal hydrops; - Provide guidance for other testing, such as amniocentesis, chorionic villus sampling, and cordocentesis or procedures such as intrauterine blood transfusions or other in-utero fetal therapeutic procedures. Not Medically Necessary:
Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Coverage Guidelines take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The members contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. CPT Only American Medical Association Page 2 of 6

Clinical UM Guideline
Ultrasound in Maternity Care in the Outpatient Setting
Ultrasound in maternity care is considered not medically necessary for: Assessment of fetal well being, in the absence of the signs or symptoms listed above; Only sex determination of the fetus; Providing a keepsake picture of the baby for the parents.

CG-RAD-04

Place of Service/Duration
Place of Service: Duration: Outpatient Variable depending on status of mother and fetus

Coding
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 76801-76802 76805

76810

76811-76812 76815

76816

76817 76818-76819 76856 76857

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus Ultrasound, pregnant uterus, real time with image documentation, transvaginal Fetal biophysical profile Ultrasound, pelvic (non obstetric), real time with image documentation; complete Ultrasound, pelvic (non obstetric), real time with image documentation; limited or followup (eg, for follicles)

ICD-9 Procedure 88.78 ICD-9 Diagnosis 218.0-218.9 219.0-219.9

Diagnostic ultrasound of gravid uterus

Uterine leiomyoma Other benign neoplasm of uterus

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Coverage Guidelines take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The members contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. CPT Only American Medical Association Page 3 of 6

Clinical UM Guideline
Ultrasound in Maternity Care in the Outpatient Setting
236.0-236.2 621.0-621.9 622.5 630-631 632 633.00-633.91 634.00-634.92 635.00-635.92 637.00-637.92 638.0-638.9 640.00-640.93 641.00-641.93 642.00-642.93 643.00-643.93 644.00-644.20 645.10-645.23 646.00-646.93 647.00-647.93 648.00-648.93 649.00-649.73 651.00-651.93 652.00-652.93 653.00-653.93 654.00-654.94 655.00-655.93 656.00-656.93 657.00-657.03 658.00-658.93 665.00-667.14 678.00-678.13 679.00-679.14 752.0-752.49 760.0-760.9 761.0-761.9 762.0-762.9 763.0-763.9 764.00-764.99 765.00-765.29 766.0-766.22 768.0 V19.5 V23.0-V23.9 V25.42 V26.3 V28.0-V28.9 V89.01-V89.09

CG-RAD-04

Neoplasm of uncertain behavior Disorders of uterus Incompetence of cervix Hydatidiform mole Missed abortion Ectopic pregnancy Spontaneous abortion Legally induced abortion Unspecified abortion Failed attempted abortion Hemorrhage in early pregnancy Antepartum hemorrhage, abruption placentae, and placenta previa Hypertension complicating pregnancy, childbirth, and the puerperium Excessive vomiting in pregnancy Early or threatened labor Late pregnancy Other complications of pregnancy Infectious and parasitic conditions in the mother, complicating pregnancy Other current conditions in the mother, complicating pregnancy Other conditions or status of the mother complicating pregnancy, childbirth, or the puerperium Multiple gestation Malposition and malpresentation of fetus Disproportion Abnormalities of organs and soft tissue of pelvis Known or suspected fetal abnormality affecting management of the mother Other fetal and placental problems affecting management of mother Polyhydramnios Other problems associated with amniotic cavity and membranes Other obstetrical trauma, Postpartum hemorrhage, Retained placenta or membranes Other fetal conditions (fetal hematologic conditions, fetal conjoined twins) Complications of in utero procedures (maternal, fetal) Congenital anomalies of female genital organs Fetus or newborn affected by maternal conditions Fetus or newborn affected by maternal complications of pregnancy Fetus or newborn affected by complications of placenta, cord and membranes Fetus or newborn affected by other complications of labor and delivery Slow fetal growth and fetal malnutrition Disorders relating to short gestation and low birthweight Disorders relating to long gestation and high birthweight Fetal death from asphyxia or anoxia before onset of labor or at unspecified time Family history of congenital anomalies Supervision of high-risk pregnancy Intrauterine contraceptive device Genetic counseling and testing Antenatal screening for abnormalities Suspected maternal and fetal conditions not found

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Coverage Guidelines take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The members contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. CPT Only American Medical Association Page 4 of 6

Clinical UM Guideline
Ultrasound in Maternity Care in the Outpatient Setting
Discussion/General Information

CG-RAD-04

The American College of Obstetricians and Gynecologists (ACOG) updated their practice bulletin in December 2004 for obstetric ultrasound. Their conclusions and recommendations follow:

Conclusions: Ultrasound examination is an accurate method of determining gestational age, fetal number, viability and placental location. Gestational age is most accurately determined in the first half of pregnancy. The ability of ultrasonography to diagnose major fetal anomalies is well established. The diagnosis of fetal growth abnormalities with ultrasonography is not precise. Ultrasonography is safe for the fetus when used appropriately. Specific indications are the best basis for the use of ultrasonography in pregnancy. The optimal timing for a single ultrasound examination in the absence of specific indications for a first-trimester examination is at 1620 weeks of gestation. Summary of Recommendations The following recommendation is based on limited or inconsistent scientific evidence: Serial ultrasonograms to determine the rate of growth should be obtained approximately every 24 weeks. The following recommendations are based primarily on consensus and expert opinion: Casual use of ultrasonography, especially during pregnancy, should be avoided. Before an ultrasound examination is performed, patients should be counseled about the limitations of ultrasonography for diagnosis (ACOG, 2004). Diagnostic ultrasound studies of the fetus are generally considered to be safe during pregnancy. This diagnostic procedure should be performed only when there is a valid medical indication, and the lowest possible ultrasonic exposure setting should be used to gain the necessary diagnostic information (ACR, 2003). After delivery, ultrasound imaging can be used to evaluate complications such as retained placenta and hematomas.

References
1. American College of Obstetricians and Gynecologists (ACOG). Antepartum Fetal Surveillance. ACOG Practice Bulletin Number 9, October 1999. 2. American College of Obstetricians and Gynecologists (ACOG). Ultrasonography in Pregnancy. ACOG Practice Bulletin Number 58, December 2004. 3. American College of Obstetricians and Gynecologists (ACOG). Postpartum Hemorrhage. ACOG Practice Bulletin Number 76, October 2006. 4. American College of Radiology (ACR). Practice Guideline for the Performance of Antepartum Obstetrical Ultrasound. October 2003. Available at: http://www.aspb.ro/documente/protocoaleclinice/Radiologie/ACR_Practice_Guideline_for_the_Performance_o f_Antepartum_Obs.PDF Accessed on January 23, 2008. 5. Bricker L, Neilson JP. Routine ultrasound in late pregnancy (after 24 weeks gestation). Cochrane Database of Systematic Reviews 2000, Issue 1. Art. No.: CD001451. DOI: 10.1002/14651858.CD001451.
Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Coverage Guidelines take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The members contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. CPT Only American Medical Association Page 5 of 6

Clinical UM Guideline
Ultrasound in Maternity Care in the Outpatient Setting

CG-RAD-04

6. Bricker L, Neilson JP. Routine Doppler ultrasound in pregnancy. Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD001450. DOI: 10.1002/14651858.CD001450. 7. Neilson JP. Ultrasound for fetal assessment in early pregnancy. Cochrane Database of Systematic Reviews 1998, Issue 4. Art. No.: CD000182. DOI: 10.1002/14651858.CD000182. 8. Warshak C, Eskander R, Hull A, et al. Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. J Obstet Gyn. 2006; 108(3):573-578.

Index
Maternal Ultrasound Obstetric

Document History
Status Reviewed Reviewed Date 10/01/2008 07/01/2008 11/29/2007 Action Updated coding section with 10/01/2008 ICD-9 changes. Coding updated with additional diagnosis codes. Medical Policy & Technology Assessment Committee (MPTAC) review. Title revised to specify place of service. Term intrauterine growth retardation replaced with intrauterine growth restriction. MPTAC review. Clarified and classified maternal and fetal indications. Updated references. MPTAC review. MPTAC initial document development.

Revised Reviewed New

08/23/2007 12/07/2006 12/01/2005

Pre-Merger Organizations Anthem, Inc. Anthem CO/NV Anthem Virginia WellPoint Health Networks, Inc.

Last Review Date 08/12/2004 08/01/2005

Document Number

Title None Ultrasound in Maternity Care Maternity Ultrasound None

UMR 21 Medical Coverage Guideline

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Coverage Guidelines take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The members contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. CPT Only American Medical Association Page 6 of 6