CurrentAetnaPolicy 0199

Ultrasound for Pregnancy

This clinical policy bulletin defines Aetna's medical necessity, experimental/investigational indications, and coding guidance for obstetric ultrasound examinations during pregnancy and who is affected (pregnant members/providers).

Policy Summary

PayerAetna

PolicyUltrasound for Pregnancy

Policy CodePolicy 0199

Change TypeNo material changes

Effective DateFeb 5, 1998

Next Review DateFeb 8, 2024

Key ActionDocument the clinical indication and required exam components when requesting or performing a detailed fetal anatomic ultrasound (CPT 76811); limit to one detailed exam per pregnancy per practice unless new clinical circumstances arise.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1detailed fetal anatomic examination per pregnancy per practice recommended (no more than)

>=30obesity BMI threshold (indication)

3.0 mmnuchal translucency threshold (1st trimester)

32% vs 19%antenatal detection of SGA (intervention vs usual care)

13,046participants in routine third-trimester trial

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Coverage Criteria: Ultrasound in Pregnancy

Denial Risk

Elective / Not Medically Necessary

Ultrasound to determine fetal sex or to provide keepsake images is considered not medically necessary and is a denial risk when billed as a diagnostic or covered obstetrical ultrasound.

Elective/keepsake fetal imaging (e.g., solely to determine fetal sex or provide parent keepsake images) — Not medically necessary; do not bill as CPT 76805/76811 for coverage purposes.

Coding Guidance and Thresholds

Covered CPT Codes (when criteria met)CPTCovered

76811	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation [second and/or third trimester].
76812	Each additional gestation (List separately in addition to code for primary procedure).
76813	Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation.
76814	Each additional gestation (List separately in addition to code for primary procedure).
76801	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation.
76802	Each additional gestation (List separately in addition to code for primary procedure).
76817	Ultrasound, pregnant uterus, real time with image documentation, transvaginal.
76830	Ultrasound, transvaginal.

Not covered CPT Codes for listed indications (3D/4D rendering)CPTNot Covered

76376	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation.
76377	3D rendering requiring image postprocessing on an independent workstation.

Related HCPCS / Drug Code (listed)HCPCS

J1953

Injection, levetiracetam, 10 mg.

ICD-10 Codes (examples listed as covered for detailed fetal ultrasounds if criteria met)ICD-10

A92.5	Zika virus disease.
B06.00	Rubella [German measles].
E66.01	Morbid (severe) obesity due to excess calories [obesity with a BMI of 30 or>].
O09.811	Supervision of pregnancy resulting from assisted reproductive technology.
O24.011	Diabetes mellitus in pregnancy.
O35.10X	Maternal care for (suspected) chromosomal abnormality in fetus.
Q30.1	Agenesis and underdevelopment of nose [absent or hypoplastic nasal bone].

ICD-10 Codes Not Covered for Indications ListedICD-10Not Covered

B20	Human immunodeficiency virus [HIV] disease.
F12.10	Cannabis abuse.
G70.00	Myasthenia gravis.
J84.03	Idiopathic pulmonary hemosiderosis.

Referenced procedure codesCPT

76811

Fetal ultrasound, detailed anatomic examination

Covered/Referenced CPT CodesCPTCovered

76811

Detailed fetal anatomic ultrasound (includes components of 76805 plus detailed survey)

Referenced CPT Codes and useCPT

76811	Ultrasound, pregnant uterus, real time with image documentation, detailed anatomic (referenced in context as detailed anatomic ultrasound)
76816	Ultrasound, pregnant uterus, real time with image documentation, follow-up (recommended after 76811 when appropriate)
76805	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (>= 14 weeks 0 days) - used for routine screening to determine number of fetuses, survey of anatomy, 4-chamber heart view, cord insertion, amniotic fluid, adnexa when visible

Referenced ICD-10 CodeICD-10

Z36	Encounter for antenatal screening of mother (used with CPT 76805 for routine screening ultrasound)

inv-42: First trimester nuchal translucency threshold — Key numeric threshold used in clinical criteria.

First-trimester nuchal translucency>= 3.0 mm

ContextReferenced as a soft sonographic marker of aneuploidy warranting detailed anatomic evaluation

Trimester specifiedFirst trimester

inv-43: Obesity BMI threshold — BMI threshold considered obesity complicating pregnancy (qualification for detailed ultrasound).

Obesity BMI thresholdBMI >= 30 kg/m2

UseIndication for performing a detailed fetal anatomic ultrasound when obesity complicates pregnancy

Source guidanceAIUM/SMFM referenced threshold for obesity-related indication

inv-44: Obesity BMI threshold — BMI threshold repeated (alternate chunk).

Obesity BMI threshold (alternate)>= 30 kg/m2

NoteAIUM and SMFM statements clarified earlier reports using varied definitions and recommended BMI >=30 kg/m2 for indicating 76811

ApplicationPrepregnancy or early pregnancy BMI used for indication assessment

inv-45: Fundal indentation length — 3D-US criterion for subseptate vs arcuate uterus differentiation.

Fundal indentation length threshold>= 12.5 mm

Use3D-US coronal view parameter to improve differentiation of subseptate versus arcuate uterus

PerformanceCut-off produced AUC 0.99 vs MRI reference standard in study

inv-46: Indentation tip angle — 3D-US criterion for subseptate vs arcuate uterus differentiation.

Indentation tip angle threshold<= 89.25 degrees

Use3D-US coronal view parameter to distinguish subseptate from arcuate uteri

Study noteAngle threshold combined with indentation length improved diagnostic accuracy vs MRI

inv-47: Short cervical length — Numeric threshold for short cervix.

Short cervical length threshold< 25 mm

Clinical relevanceShort cervix is a risk indicator for spontaneous preterm birth, including in some uterine anomaly subgroups

Measurement timingReported predictive utility varied by gestational age (e.g., 24 weeks more predictive in one study)

inv-48: Fetal ovarian cyst size — Threshold referenced for investigation.

Fetal ovarian cyst size threshold> 4 cm

ContextVoluminous unilateral fetal ovarian cysts (>4 cm) were investigated for association with Gsα mutation (McCune‑Albright syndrome) in a case series

RecommendationAuthors recommended mutation testing in newborns with cysts requiring aspiration; detailed fetal US not specified as management tool

Provider Actions, Documentation & Prior Authorization

Prior Authorization

Coverage note: CPT 76811 only when policy criteria met; 3D/4D rendering codes not covered

Detailed fetal anatomic examination (e.g., CPT 76811) is covered only when the selection criteria in this policy are met; 3D/4D rendering codes (76376, 76377) are not covered for the indications listed.

Covered CPT when selection criteria met: 76811 and related codes
3D/4D rendering codes 76376 and 76377 are not covered for listed indications

Prior Authorization

Prior authorization guidance for CPT 76811 — document medical necessity

A detailed fetal anatomic ultrasound (CPT 76811) is indicated only when medically necessary (for known or suspected fetal anomaly or increased risk such as abnormal prenatal screening, teratogen exposure, maternal obesity, ART, Zika exposure, or untreated/inadequately treated syphilis); request prior authorization when CPT 76811 is being billed to confirm criteria are met.

Indications include known/suspected fetal anatomic or genetic abnormality, abnormal screening, ART, obesity (prepregnancy BMI ≥30 kg/m2), Zika exposure, and untreated/inadequately treated syphilis

Definitions and Key Terms

inv-83: Standard examination — Components included in a standard obstetric ultrasound exam.

Standard examination componentsFetal presentation; amniotic fluid volume; cardiac activity; placental position; fetal biometry; fetal number; an anatomic survey (abdomen, chest, extremities, head/face/neck, spine)

Anatomic survey specificsAbdomen: stomach, kidneys, bladder, umbilical cord insertion and vessel number; Head/face/neck: cerebellum, choroid plexus, cisterna magna, lateral ventricles, midline falx, cavum septi pellucidi, upper lip

Sex determinationSex reported only when medically indicated (e.g., multiple gestation) in low-risk pregnancies

inv-84: Limited examination — Defined as a focused scan to answer a specific question; does not replace a standard exam.

DefinitionA focused or limited examination performed to answer a specific question (e.g., confirm cardiac activity, fetal presentation) and does not replace a standard exam

Background Evidence and Key Findings

Ultrasonography during pregnancy should be performed only when a valid medical indication exists. ACOG guidance recommends an optimal timing for the routine anatomic survey at approximately 18–20 weeks' gestation, while first‑trimester ultrasound is reserved for specific clinical indications such as confirmation of intrauterine pregnancy, cardiac activity, multiple gestation, dating, or evaluation of bleeding or suspected ectopic pregnancy.

Randomized trial evidence does not support offering routine third‑trimester ultrasound to all low‑risk pregnant women to reduce severe adverse perinatal outcomes. Although routine third‑trimester biometry scans increased antenatal detection of small‑for‑gestational‑age fetuses, the trial showed no significant reduction in a composite of severe adverse perinatal outcomes (intervention 1.7% vs usual care 1.8%; adjusted OR 0.88, 95% CI: 0.70–1.20) and was associated with more inductions of labor.

A large systematic review of placental biomarkers plus ultrasound (91 studies; 175,426 women) found that US‑estimated fetal weight (US‑EFW) was the most accurate single test for detecting small‑for‑gestational‑age infants; biochemical placental markers alone performed worse. The reviewers concluded that studies combining ultrasound and placental biomarkers are needed because no studies were identified evaluating combined ultrasound plus blood tests for detection of SGA or stillbirth.

Evidence supporting detailed fetal anatomic ultrasound includes studies of specific anatomic components and specialized imaging techniques. Examples include prospective evaluations of 4D‑STIC for early fetal cardiac assessment, 3D OMNIVIEW reconstruction for cerebral midline structures, and detailed SMFM‑defined components integral to CPT 76811 (intracranial, facial, spinal, chest, cardiac, abdominal, genital, limb, and placenta/cord assessments). These contexts and anatomical components are used to guide when a level II/detailed anatomic survey is appropriate and which structures should be documented.

Policy Dates & Revision History

2023-07-11policy_reviewLatest

Policy last reviewed on 07/11/2023.

1998-02-05effective_date

Policy effective date established as 02/05/1998.

2024-02-08next_review_scheduled

Next scheduled policy review on 02/08/2024.

Policy Summary

PayerAetna

PolicyUltrasound for Pregnancy

Policy CodePolicy 0199

Change TypeNo material changes

Effective DateFeb 5, 1998

Next Review DateFeb 8, 2024

SourceLink

On This Page

SMFM expects detailed exams to be rare outside referral practices — document indication when seeking authorization

Prior Authorization

Prior auth consideration: routine third‑trimester ultrasounds in low‑risk pregnancy

Evidence does not support routine third‑trimester ultrasound for all low‑risk pregnancies to reduce severe adverse perinatal outcomes; prior authorization may be required when scans are requested solely for routine late‑pregnancy screening in low‑risk patients.

Routine two biometry scans (≈28–30 and 34–36 weeks) increased antenatal SGA detection but did not reduce severe adverse perinatal outcomes (adjusted OR 0.88, 95% CI 0.70–1.20).
Consider prior authorization for routine third‑trimester scans in low‑risk patients.

Prior Authorization

Prior auth consideration: detailed (Level II) exams require advanced training and specific indications

Level II/detailed fetal anatomic (detailed) examinations should be undertaken only by providers with the necessary advanced training and are indicated for prior or current suspected/known fetal anatomic or chromosomal abnormalities or other high‑risk scenarios.

Indications include previous anomalous fetus, suspected or known fetal anomaly in current pregnancy, known fetal growth disorder, or pregnancy complications affecting the fetus
Ensure provider has requisite advanced skills when requesting authorization

Prior Authorization

Prior affected‑pregnancy indication — document prior anomalous fetus

A detailed fetal anatomic ultrasound is supported when there is a prior affected pregnancy (for example a previous fetus with omphalocele); indicate this history when requesting advanced imaging or authorization.

Prior Authorization

CPT 76811 definition and components — cite SMFM 2012 when requesting auth

CPT 76811 is defined as a detailed fetal anatomic ultrasound and the policy references the SMFM (2012) list of constituent anatomic components; reference CPT 76811 when requesting authorization and document the exam components performed.

CPT 76811 includes components of routine ultrasound plus a detailed fetal anatomical survey per SMFM 2012
Document which SMFM components were evaluated when billing 76811

Billing Rule

CPT coding guidance: use 76816 for follow‑up and 76805 (+ Z36) for routine screening

Report follow‑up ultrasound after a detailed anatomic exam as CPT 76816; routine screening ultrasounds should be reported as CPT 76805 with ICD‑10 code Z36 when no maternal or fetal indications are present.

Follow‑up after 76811 → report CPT 76816
Routine screening (no indications) → report CPT 76805 and ICD‑10 Z36

Note

Confirm plan‑specific prior authorization requirements

Refer to this Clinical Policy Bulletin and specific plan provisions for any prior authorization requirements; the bulletin is advisory and plan‑specific authorization rules apply.

Step Therapy

Limit: one detailed fetal anatomic exam per pregnancy per practice (repeat only with new clinical reason)

SMFM expects no more than one detailed fetal anatomic ultrasound per pregnancy per practice when medically necessary; repeat detailed exams require new clinical circumstances, referral, or second opinion to justify another detailed exam.

One detailed anatomic exam per pregnancy per practice is expected
Repeat detailed exam only for new diagnosis, referral to another MFM practice, or extenuating circumstances

Step Therapy

Step: avoid repeat detailed anatomic exams without new findings or referral

If a detailed anatomic examination has already been performed by the practice, avoid repeating the detailed exam unless new findings or a referral/second opinion justify another exam.

Step Therapy

Preferred initial test for suspected placental dysfunction: ultrasound EFW over biochemical markers alone

For suspected placental dysfunction or screening for SGA, consider ultrasound estimation of fetal weight (US‑EFW) as the primary test; biochemical placental markers alone have lower accuracy and combined testing requires further study.

US‑EFW was the most accurate single test for detecting SGA (DOR 21.3) in systematic review
Biochemical markers alone had lower accuracy; no studies evaluated combined US plus blood tests

Step Therapy

Stepwise use of third‑trimester ultrasounds — authorize based on clinical risk, not routine

Routine addition of third‑trimester screening ultrasounds in low‑risk pregnancy increased antenatal detection of SGA but did not reduce severe adverse perinatal outcomes and led to more inductions; authorization decisions should consider clinical risk rather than automatic routine scans.

Intervention increased SGA detection (32% vs 19%) but no significant reduction in severe adverse outcomes (1.7% vs 1.8%)
Routine third‑trimester scans in low‑risk patients may require justification for authorization

Step Therapy

Imaging sequence for uterine anomaly evaluation: TVUS/hysterosonography first; 3D‑US adjunctive

When evaluating suspected septate versus arcuate uterus, begin with 2D transvaginal ultrasound and hysterosonography; 3D ultrasound may be used adjunctively to improve coronal assessment and diagnostic accuracy prior to invasive interventions.

TVUS and hysterosonography have high sensitivity for septate uterus detection
3D‑US improves coronal reconstruction and differentiation when indicated

Documentation Required

Required exam documentation: state indication and technical limitations

Document the clinical indication for each ultrasound (e.g., fetal presentation, amniotic fluid concern, suspected anomaly) and any technical limitations when anatomy cannot be visualized; specialized/detailed exams should be performed by experienced operators.

Record the indication and any technical limitations (fetal position, maternal habitus) in the report
Ensure experienced operator performed specialized/detailed exams

Documentation Required

Document focused assessment and follow‑up when specific sonographic markers are found

When specific sonographic findings (e.g., single umbilical artery or choroid plexus cyst) are identified, document the focused assessment performed, whether a detailed survey by an experienced provider was completed, and relevant risk factors (maternal age, screening/diagnostic results, family history).

Documentation Required

4D‑STIC imaging documentation: record volume quality, approach, and Doppler use

When using 4D‑STIC for early fetal echocardiography, document image/volume quality, the scanning approach (transvaginal vs transabdominal), and use of color or spectral Doppler because visualization and diagnostic accuracy correlate with volume quality and technique.

Documentation Required

Document timing and outcomes when performing routine third‑trimester scans

If routine third‑trimester biometry scans are performed, document timing (e.g., 28–30 and 34–36 weeks), biometry findings, and any subsequent management actions (inductions, fetal growth restriction protocols) to support medical necessity.

Documentation Required

Document detailed exam components and indication for prior affected‑pregnancy cases

When performing a detailed fetal anatomic examination for prior fetal or chromosomal abnormality, document the indication, that a level II/comprehensive exam and fetal echocardiogram were performed, and list the anatomical systems evaluated.

Documentation Required

Key clinical documentation to support medical necessity: prior affected pregnancy, uterine anomaly, UCI, and cord insertion

Document prior affected pregnancy (for example prior fetus with omphalocele), specific uterine anomaly diagnosis or suspicion (with imaging modality used), umbilical cord coiling index results and percentiles, and placental cord insertion findings to support medical necessity for detailed ultrasound when applicable.

Documentation Required

Document the CPT 76811 components per SMFM (2012) in the report

When performing CPT 76811, document the exam components per SMFM (2012) — cranial, facial, spinal, chest, cardiac, abdominal, genitalia, limb, and placenta/cord evaluations — and note which integral components were assessed.

Documentation Required

Report non‑visualized components and reasons in the ultrasound report

If required fetal or maternal components are non‑visualized (due to fetal position, late gestational age, or maternal habitus), explicitly state which components were non‑visualized and the clinical reason in the ultrasound report to meet billing requirements.

Note

Advisory: provider responsibility and plan‑specific authorization rules

Treating providers are responsible for medical advice and treatment; this Clinical Policy Bulletin is advisory and plan‑specific provisions and authorization rules govern coverage decisions.

Denial Risk

Denial risk: repeat detailed anatomic exams without new clinical reason may be disallowed

Performing more than one detailed fetal anatomic ultrasound per pregnancy/practice without a new diagnosis or extenuating circumstances may not be supported; SMFM expects only one such exam per pregnancy per practice and repeat exams require justification.

Denial Risk

Denial risk: routine third‑trimester scans in low‑risk pregnancies lack evidence of outcome benefit

Evidence does not support routine third‑trimester ultrasound to reduce severe adverse perinatal outcomes in low‑risk pregnancies; requests for routine late‑pregnancy scans in low‑risk patients may be denied without clinical justification.

Denial Risk

Syphilis‑related evaluation: document sonographic signs and specialist referral

If sonographic signs of fetal or placental syphilis (e.g., hepatomegaly, ascites, hydrops, fetal anemia, or a thickened placenta) are present after 20 weeks, these findings indicate higher risk and should prompt obstetric specialist management; failure to evaluate or document appropriately could risk inadequate management.

Denial Risk

Denial risk when indication is not in consensus report (e.g., septate uterus, abnormal UCI)

The Consensus Report did not list septate/arcuate uterus or hypo‑/hyper‑coiled umbilical cord as formal indications for a detailed fetal anatomic exam; absence of these accepted indications may be a risk for coverage denial if no other indications are documented.

Denial Risk

Denial risk: incomplete documentation of non‑visualized components may affect coverage

Failure to document non‑visualized required fetal or maternal components (and the reason, e.g., fetal position, late gestational age, maternal habitus) in the ultrasound report may prevent meeting billing requirements and jeopardize coverage.

UsesMay be performed in first trimester to evaluate interval growth, estimate amniotic fluid, evaluate cervix, or assess cardiac activity

LimitationNot a substitute for a full anatomic survey when indicated

inv-85: Specialized/detailed examination — Targeted anatomic exam when anomaly suspected; requires experienced operators.

DefinitionTargeted anatomic exam performed when an anomaly is suspected or for known risk factors; performed by experienced operators

IndicationsPerformed for suspected anomalies based on history, labs, or prior imaging; includes fetal Doppler, biophysical profile, fetal echocardiography as needed

Frequency guidanceSMFM expects detailed exams to be uncommon outside referral practices and limited to medically necessary situations

inv-86: Detailed fetal anatomic examination — Comprehensive ultrasound (CPT 76811) targeted to identify fetal anatomic/genetic abnormalities.

Definition (CPT 76811)Comprehensive ultrasound targeted to identify fetal anatomic or genetic abnormalities (detailed fetal anatomic examination)

UseIndicated when known or suspected fetal anatomic/genetic abnormality or increased risk factors (e.g., AMA, diabetes, abnormal prenatal screen)

ComponentsIncludes all routine components plus a detailed survey per SMFM (cranial, facial, spinal, chest, cardiac, abdominal, genitalia, limbs, placenta/cord)

inv-87: Focused ultrasound assessment — Limited scan for re-examination of a specific organ/system or fetal size assessment.

DefinitionA limited scan for re-examination of a specific organ/system known or suspected to be abnormal or for focused fetal size assessment (e.g., BPD, AC, FL)

Reporting guidanceFollow-up scans after detailed exam are reported as CPT 76816 when appropriate

PurposeUsed for targeted reassessment rather than full anatomic resurvey

inv-88: 3D/4D ultrasound — Three- or four-dimensional volumetric ultrasound techniques; adjunctive to 2D.

DefinitionThree- or four-dimensional volumetric ultrasound techniques that provide enhanced spatial and dynamic views as adjuncts to 2D imaging

RoleMay improve visualization of certain anomalies (facial, neural tube, skeletal) and reduce scan time but not proven to change outcomes over 2D

Coding noteNo specific CPT codes for 3D/4D fetal ultrasound; 3D/4D rendering codes (76376/76377) are not covered for listed indications

inv-89: STIC (Spatio-Temporal Image Correlation) — Automated 3D/4D acquisition method for volumetric datasets.

Definition (STIC)Automated 3D/4D acquisition method that sweeps to acquire a volumetric dataset composed of many 2D frames for offline review

ApplicationUsed for fetal cardiac evaluation (4D‑STIC); visualization and diagnostic accuracy depend on volume quality, approach (transvaginal vs transabdominal), and use of color Doppler

PerformanceIn one study, 4D‑STIC accuracy for CHD diagnosis was 88.7% (but 2D early fetal echocardiography showed higher accuracy unless high-quality volumes obtained)

inv-90: EFW (Estimated Fetal Weight) — Ultrasound-based estimation of fetal weight used to identify SGA and screen for growth restriction.

DefinitionUltrasound-based estimation of fetal weight used to identify small‑for‑gestational‑age infants and to screen for fetal growth restriction

AccuracyUS‑EFW was the most accurate single test for detecting SGA in a systematic review (DOR 21.3)

Role in pathwaysPreferred initial test for suspected placental dysfunction in coverage considerations

inv-91: Detailed fetal anatomic examination (Level II) — Comprehensive fetal structural survey requiring advanced training.

DefinitionComprehensive fetal structural survey (Level II) requiring practitioners with advanced training; indicated for prior affected pregnancy, suspected/known fetal anomalies, known fetal growth disorder, or complications affecting the fetus

Operator requirementShould be performed by providers with necessary advanced skills and expertise

Overlap with CPT 76811Level II detailed fetal anatomic exam corresponds to CPT code 76811 and includes SMFM‑listed components

inv-92: Uterus didelphys — Definition and diagnostic note.

DefinitionDuplication of reproductive structures generally limited to the uterus and cervix (double uterus and two cervices); diagnosis typically by ultrasound showing two widely separated uterine horns with deep fundal indentation

Associated anomaliesMay be associated with obstructed hemivagina and ipsilateral renal agenesis in 15–20% of cases

ImagingMRI rarely required to make definitive diagnosis

inv-93: antenatal umbilical coiling index (aUCI / UCI) — Definition and categorization for coiling index.

Definition (aUCI / UCI)Calculated as the reciprocal of the mean length (cm) of one complete coil; categorized as hypo‑coiled (<10th percentile), normo‑coiled (10th–90th), or hyper‑coiled (>90th)

Measurement windowTypically assessed at 16–21 weeks in referenced studies with reference curves available

Clinical evidenceAssociation with adverse outcomes is inconsistent in unselected low‑risk populations

inv-94: subseptate vs arcuate uterus differentiation criteria (3D-US) — Fundal indentation length and indentation tip angle thresholds for differentiation.

Differentiation criteriaFundal indentation length >= 12.5 mm AND indentation tip angle <= 89.25 degrees

Use3D‑US coronal view parameters to distinguish subseptate from arcuate uterus with improved agreement vs MRI

EvidenceStudy showed high AUCs (0.99 for indentation length; 0.97 for tip angle) and substantial kappa agreement with MRI

inv-95: velamentous cord insertion (VCI) — Definition and associated risks.

DefinitionVelamentous cord insertion (VCI): umbilical vessels insert into membranes rather than the placental disk; associated with increased risk of low cord pH, low 5‑min Apgar, cord avulsion and other adverse outcomes

AssociationVCI is strongly associated with vasa previa and with adverse perinatal outcomes including preterm birth and emergency cesarean in some studies

Screening accuracyPrenatal detection rates vary; TAS screening shows good specificity but sensitivity is variable; combined TA‑ and TV‑CDUS had high sensitivity in one study

inv-96: Velamentous cord insertion (VCI) — Additional reference chunk for definition and risks.

Definition (additional)An umbilical cord attachment to the membranes surrounding the placenta rather than to the placental disk, often linked with vasa previa and adverse outcomes

Incidence rangeEstimated incidence in singleton pregnancies 0.4%–11% (higher in twins and IVF pregnancies)

Management gapsNo standardized post‑screening management pathway established in literature reviews

inv-97: Detailed fetal anatomic ultrasound (CPT 76811) — Definition and components.

Definition (CPT 76811)Detailed fetal anatomic ultrasound includes all components of routine fetal ultrasound (76805) plus a detailed fetal anatomical survey per SMFM (2012)

Integral componentsSMFM lists cranial, facial, spinal, chest, cardiac, abdominal, genitalia, limbs, placenta/cord assessments among components, with some marked as integral

DocumentationProviders should document the components performed to support CPT 76811 billing

inv-98: Follow-up ultrasound after detailed anatomic exam — CPT 76816 reference.

Follow-up CPT codeCPT 76816 — follow-up ultrasound after detailed anatomic exam

When usedReported for focused assessment of fetal size or detailed re‑examination of a specific organ/system after CPT 76811

Coding guidanceFollow-up vs routine screening (76805 + Z36) distinction emphasized

inv-99: Routine screening ultrasound — CPT 76805 (ICD-10 Z36) definition for routine screening when no indications present.

Routine screening codeCPT 76805 (with ICD-10 Z36) — routine screening ultrasound when no maternal or fetal indications are present

UseUsed to determine number of fetuses, basic anatomy survey, 4-chamber heart view, cord insertion, amniotic fluid, adnexa when visible

TimingPerformed after first trimester (>= 14 weeks 0 days) for routine screening

inv-100: Clinical Policy Bulletin — Advisory note that policy bulletins assist in administering benefits and are not offers of coverage.

Advisory natureClinical Policy Bulletins assist in administering benefits and do not constitute offers of coverage or medical advice

Plan provisionsCoverage decisions are subject to specific plan/program benefits and prior authorization rules

AppealsDecisions inconsistent with plan benefits may be appealed per plan procedures

This Clinical Policy Bulletin is advisory and provides a general description of plan benefits; it does not constitute a contract or replace specific plan provisions. Providers should consult applicable plan documents and prior authorization rules for any binding coverage or authorization requirements.