Arizona Complete Health prenatal ultrasound Policy Update | OpenPayer
ModifiedArizona Complete HealthPolicy CP.MP.38
Ultrasound in Pregnancy
Medical necessity criteria for obstetric ultrasound examinations during pregnancy and the conditions under which specific ultrasound CPT codes are covered for members of Arizona Complete Health (Centene-affiliated health plans). Applies to providers performing prenatal ultrasound imaging.
Policy Summary
PayerArizona Complete Health
PolicyUltrasound in Pregnancy
Policy CodePolicy CP.MP.38
Change TypeCriteria reorganizationfrequency and coding updates
Effective Date
Next Review Date
Key ActionConfirm exam timing and frequency against policy limits and document medical necessity (including prior preterm birth history, cervical length, transfer-of-care status, or abnormal hCG trends) when requesting authorization.
Table 1 updated to include standardized criteria for all prior preterm birth and for a short cervix; exam time period updated to 18 0/7 - 22 6/7 weeks for no prior preterm birth.
Maximum number of transvaginal ultrasounds (TVU) per pregnancy changed (total allowed TVUS per pregnancy = 13; maximums for prior preterm birth updated).
Table 4 (Diagnosis Codes that Support Medical Necessity for First Detailed Fetal Ultrasound) was updated to add numerous ICD-10 codes and ranges.
Clarification added about transvaginal ultrasounds performed in an office setting and addition of medical necessity for an additional standard second or third trimester ultrasound when transferring to a new provider.
Removed I. through V. list under Policy/Criteria for clarity and added medical necessity in Criteria II. for an additional standard second or third trimester ultrasound if transferring to a new provider.
Updated Table 1 standardized criteria for all prior preterm birth and for a short cervix and updated exam time period to between 18 0/7 and 22 6/7 weeks for no prior preterm birth.
Detailed Fetal Ultrasound diagnosis table updated to include multiple O35.xx and A93.0 codes.
Criteria V updated to include abnormally trending HCG levels in regard to a follow-up ultrasound in the first trimester.
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1standard first trimester ultrasound allowed per pregnancy (CPT 76801)
1standard second/third trimester ultrasound allowed per pregnancy (CPT 76805)
1detailed anatomic ultrasound allowed per pregnancy when indicated (CPT 76811)
13total allowed transvaginal ultrasounds (TVUS) per pregnancy
3D/4D3D and 4D ultrasounds considered not medically necessary
18 0/7–22 6/7timing for standard second trimester exam when no prior preterm birth
Coverage Criteria and Medical Necessity
Medically Necessary Ultrasounds and Limits
Covered when the following conditions are met
First trimester standard ultrasound: One standard first trimester ultrasound (CPT 76801) allowed per pregnancyper pregnancy
Subsequent standard first trimester ultrasounds are considered not medically necessary; limited or follow-up ultrasound (76815 or 76816) should suffice.
Second/third trimester standard ultrasound: One standard second or third trimester ultrasound (CPT 76805) allowed per pregnancyper pregnancy
Subsequent standard second/third trimester ultrasounds are considered not medically necessary; an additional standard second/third trimester ultrasound is medically necessary if a new provider is taking over care.
Detailed anatomic ultrasound: One detailed anatomic ultrasound (CPT 76811) allowed per pregnancy when performed to evaluate suspected fetal anomaly based on history, laboratory abnormalities, clinical evaluation, or suspicious results from limited/standard ultrasoundper pregnancy
Must be billed with an appropriate high‑risk diagnosis code from Table 4; a second detailed anatomic ultrasound is allowed only if a new MFM group takes over care, a second opinion is required, or the patient is transferred to a tertiary care center.
Transvaginal ultrasound (TVU): TVU is medically necessary in the first trimester for the same indications as a standard first trimester ultrasound and later to assess cervical length, placenta location for placenta previa, or after an inconclusive transabdominal ultrasoundup to 13 per pregnancy in office setting
Cervical length screening frequency and limits provided in Table 1 (start 16 0/7 to 24 0/7 weeks for prior preterm birth/short cervix; every 1–4 weeks; maximums per Table 1).
Medical necessity criteria (summary)
Policy covers fetal and transvaginal ultrasound exams when documented medical necessity is present according to standardized criteria (e.g., prior preterm birth, short cervix, transfer of care, abnormal HCG trends).
Standard timing for second trimester ultrasound: Standard second trimester anatomy survey should be performed between 18 0/7 and 22 6/7 weeks when there is no prior preterm birthgestational age window
Exam time period updated in Table 1.
Transvaginal ultrasound surveillance for short cervix or prior preterm birth: TVU frequency and number adjusted based on cervical length and prior preterm birth history (including increases to weekly for cervix 25–29 mm); policy applies maximum TVU limits per pregnancyTVU frequency and maximums
Total allowed TVUS per pregnancy = 13; specific maxima revised (e.g., 11 and 9) based on timing of prior preterm birth.
Additional ultrasound after transfer of care:
Revised policy highlights
Policy criteria were reorganized and clarified; specific additions include transfer-provider ultrasound and first-trimester follow-up for abnormal hCG trends.
Updated criteria highlights: Removed enumerated I–V and reorganized criteria; added medical necessity for an additional standard second or third trimester ultrasound when transferring to a new provider; updated Criteria V to include abnormally trending HCG levels for first‑trimester follow‑up; clarified transvaginal ultrasound office setting and standardized TVU criteria in Table 1.
See full policy for complete indication‑specific logic and tables.
3D and 4D ultrasounds are not covered as the policy states these modalities lack sufficient evidence of clinical utility over two‑dimensional ultrasound. Ultrasounds performed solely to determine fetal sex or to provide fetal photographs are also not covered. In addition, scans for growth evaluation performed less than two weeks apart, ultrasound to confirm pregnancy in the absence of other indications, and first‑trimester follow‑up ultrasounds when there is no pain, bleeding, or abnormally trending hCG are considered not medically necessary.
The policy notes that the lists provided under the classifications of fetal ultrasounds (Sections I and II) are not all inclusive and therefore may not enumerate every clinical scenario. Providers must use the clinical criteria in the policy (including timing, indications, and required diagnosis support) to determine medical necessity rather than relying solely on the example lists.
Coverage of ultrasound services is subject to the terms, conditions, exclusions, and limitations of each member's coverage documents. Where applicable, state Medicaid provisions take precedence; providers should consult the state Medicaid manual and plan contract language when applying these clinical criteria.
Further detailed anatomic ultrasounds beyond those specified in the policy are considered not medically necessary unless supported by the documented indications and appropriate diagnosis codes. The policy also lists the 3D rendering codes 76376 and 76377 as not medically necessary for prenatal ultrasound visualization. When additional or repeated detailed anatomic evaluation is requested, clinicians must document the specific clinical rationale and the supporting high‑risk diagnosis codes described in Table 4.
Prior versions of the policy included an 'experimental' designation in Section V; that designation has been removed in recent revisions and the policy language was updated to clarify criteria and examples without labeling the section as experimental.
This clinical policy is intended as a guide to medical necessity determinations and does not guarantee payment. Coverage decisions must be made in accordance with the member's plan documents, applicable state and federal regulations, and Health Plan administrative policies; any conflict between this policy and legal/regulatory requirements is resolved in favor of law and regulation.
Codes, Frequencies, and Timing
Covered CPT Codes (when supported by appropriate diagnosis)CPTCovered
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.
76805
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (≥14 weeks 0 days), transabdominal approach; single or first gestation.
76811
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation.
76817
Ultrasound, pregnant uterus, real time with image documentation, transvaginal.
CPT Codes considered Not Medically NecessaryCPTNot 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 with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation.
Excerpt of ICD-10 codes listed in policy supporting medical necessity or referenced tablesICD-10
A92.5
Zika virus disease.
A93.0
Oropouche virus disease.
B06.00-B06.9
Rubella [German measles].
Diagnosis codes supporting medical necessity (Table 4 and related ranges)ICD-10Covered
O35.0XX4
Maternal care for (suspected) central nervous system malformation in fetus, fetus 4
O35.0XX5
Maternal care for (suspected) central nervous system malformation in fetus, fetus 5
O35.0XX9
Maternal care for (suspected) central nervous system malformation in fetus, other fetus
O35.1XX0
Maternal care for (suspected) chromosomal abnormality in fetus, not applicable or unspecified
O35.00X0 through O35.00X9
Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified
O35.01X0 through O35.01X9
Maternal care for (suspected) central nervous system malformation or damage in fetus, agenesis of the corpus callosum
O35.02X0 through O35.02X9
Maternal care for (suspected) central nervous system malformation or damage in fetus, anencephaly
O35.03X0 through O35.03X9
Maternal care for (suspected) central nervous system malformation or damage in fetus, choroid plexus cysts
O35.04X0 through O35.04X9
Maternal care for (suspected) central nervous system malformation or damage in fetus, encephalocele
O35.05X0 through O35.05X9
Maternal care for (suspected) central nervous system malformation or damage in fetus, holoprosencephaly
TVU cervical length screening schedule — start weeks, frequency and maximums
Start windowFor women with prior preterm birth or short cervix (≤25 mm): begin TVU cervical length screening at 16 0/7 weeks and end at 24 0/7 weeks.
Frequency (prior preterm birth / short cervix)Every 1–4 weeks (increase to weekly for cervical length 25–29 mm as noted in revision notes).
No prior preterm birthSingle TVU cervical length screening: one exam between 18 0/7 and 22 6/7 weeks.
Maximums (prior preterm birth / short cervix)Maximum number of TVU for cervical length screening = 9.
Maximums (no prior preterm birth)Maximum number of TVU = 1.
Provider Responsibilities, Authorization, and Documentation
Prior Authorization
Provider Actions — Coverage, Authorization, and Documentation
Providers must follow coverage limits, coding, authorization, and documentation requirements when ordering and billing ultrasound exams in pregnancy. The rules below summarize allowed exam types and frequencies, required CPT usage, prior authorization and regulatory review expectations, diagnosis code support for detailed anatomic ultrasound (76811), and documentation and coding guidance to support medical necessity. Failure to adhere to these requirements may result in claim denial or request for additional information.
Coverage limits and CPT codes: One standard first-trimester ultrasound per pregnancy (CPT 76801) and one standard second/third-trimester ultrasound per pregnancy (CPT 76805) are allowed. One detailed anatomic ultrasound (CPT 76811) is allowed per pregnancy when indicated. Transvaginal ultrasound CPTs (e.g., 76817) are allowed per clinical indications. Follow-up or focused assessments use CPT 76815/76816 as appropriate.
Frequency/Timing and authorization: Verify allowable frequencies and timing prior to scheduling. For TVU cervical length screening follow Table 1 timing and maximums (up to 13 TVUs per pregnancy in office settings when criteria met). Additional standard second/third trimester ultrasound may be allowed when care is transferred to a new provider. Subsequent standard or detailed ultrasounds beyond allowed numbers generally require documentation of extenuating circumstances and may require prior authorization.
Prior authorization and regulatory review: Review and comply with plan-specific prior authorization requirements. For Medicare members, review applicable NCDs, LCDs, and Medicare Coverage Articles; for Medicaid, consult the state Medicaid manual. Confirm whether a prior authorization is required before performing additional or atypical exams.
Clinical Background and Rationale
Ultrasound is the primary fetal imaging tool used to determine gestational age, the number of fetuses, fetal viability, and placental location, and it guides many obstetric management decisions. Standard first‑trimester, standard second/third‑trimester, and detailed fetal anatomic ultrasound classifications correspond to gestational timing and specific clinical indications; accurate dating and targeted anatomic assessment inform management such as timing of delivery and use of antenatal interventions.
Definitions and Exam Descriptions
Standard first trimester ultrasound (76801) — performed before 14 weeks 0 days and assesses gestational sacs, viability, number
Gestational timingStandard first‑trimester ultrasound (CPT 76801) is performed before 14 weeks 0 days of gestation.
Exam contentAssesses presence, size, location, and number of gestational sacs and evaluates early first‑trimester findings including viability and cardiac activity.
Approach / CPT guidanceMay be transabdominal, transvaginal, or transperineal; when transvaginal, use CPT 76817 for billing guidance.
Standard second/third trimester ultrasound (76805) — performed after 14 weeks; includes fetal biometry and anatomic survey
Gestational timingStandard second/third trimester ultrasound (CPT 76805) is performed after 14 weeks 0 days (mid/late pregnancy).
Removed enumerated I–V criteria and reorganized policy; Table 1 standardized criteria for all prior preterm birth and short cervix and updated the standard second‑trimester exam window to 18 0/7–22 6/7 weeks for patients without prior preterm birth.
Added medical necessity provision allowing one additional standard second/third trimester ultrasound when a patient transfers to a new provider and clarified that transvaginal ultrasounds may be performed in an office setting.
Policy Summary
PayerArizona Complete Health
PolicyUltrasound in Pregnancy
Policy CodePolicy CP.MP.38
Change TypeCriteria reorganizationfrequency and coding updates
Effective Date
Next Review Date
Key ActionConfirm exam timing and frequency against policy limits and document medical necessity (including prior preterm birth history, cervical length, transfer-of-care status, or abnormal hCG trends) when requesting authorization.
One additional standard second or third trimester ultrasound may be medically necessary when a patient transfers to a new provider
transfer of care
Added to Criteria II.
First trimester follow-up ultrasound for abnormal HCG trends: A follow-up ultrasound in the first trimester may be medically necessary for abnormally trending HCG levelsabnormal HCG trends
Added to Criteria V.
TVU maximum — Total allowed TVUS per pregnancy and revised maximums based on prior preterm birth timing
Total allowed TVUS per pregnancyUp to 13 transvaginal ultrasounds per pregnancy (office setting).
Revised maximum for prior preterm birth at 14–27 weeksMaximum # TVU = 11.
Revised maximum for prior preterm birth at 28–36 weeksMaximum # TVU = 9.
Context / settingLimits clarified for TVUs performed in an office setting.
Second trimester exam timing — Between 18 0/7 and 22 6/7 weeks for no prior preterm birth
Exam windowStandard second‑trimester exam performed between 18 0/7 and 22 6/7 weeks when there is no prior preterm birth.
PurposeUsed for standard anatomic survey and fetal biometry as part of routine second‑trimester evaluation.
Authorization noteTiming updated in Table 1; check timing when authorizing additional exams or transfers of care.
Standard second trimester detailed anatomy exam window — 18 0/7 to 22 6/7 weeks
Standard windowDetailed second‑trimester anatomic exam window: 18 0/7 to 22 6/7 weeks.
IndicationPerformed when increased risk of fetal anomaly or as clinically indicated for targeted anatomic evaluation (CPT 76811).
LimitGenerally limited to one detailed anatomic ultrasound per pregnancy unless extenuating circumstances (e.g., transfer, second opinion, new diagnosis).
Transvaginal ultrasound (TVU) — definition and use for cervical length surveillance with specified frequency limits and clarification about office setting
Definition / useTransvaginal ultrasound (TVU) is used in the first trimester for standard indications and later for cervical length assessment, placenta location with placenta previa, or after inconclusive transabdominal ultrasound.
Frequency limitsCervical length screening frequency per Table 1: start at 16 0/7–24 0/7 weeks for prior preterm birth/short cervix with frequency every 1–4 weeks; up to 13 TVUs allowed per pregnancy overall.
Office setting clarificationPolicy explicitly allows up to 13 TVUs per pregnancy when performed in an office setting; revisions clarified office performance and limits.
Detailed Fetal Ultrasound definition — specialized second- or third-trimester anatomic evaluation supported by Table 4 (includes added O35.xx and A93.0)
DefinitionDetailed Fetal Ultrasound: specialized second‑ or third‑trimester anatomic evaluation intended to evaluate suspected fetal anomalies and supported by diagnosis codes listed in Table 4.
Table 4 additionsTable 4 expanded to include additional ICD‑10 codes and ranges, including multiple O35.xx entries and A93.0.
Use casePerformed when history, labs, or prior imaging indicate increased risk of anomaly and must be billed with an appropriate high‑risk diagnosis code from Table 4.
Diagnosis code support for CPT 76811: Claims for the first detailed fetal anatomic ultrasound (76811) must be billed with an appropriate high-risk diagnosis code from the policy's Table 4 (e.g., listed O35.x ranges, selected maternal/systemic diagnosis ranges such as A92.5; hematologic, rheumatologic, renal codes; selected obstetric complications). Absence of one of the listed supporting diagnosis codes on the claim may not meet medical necessity for CPT 76811.
Coverage decisions and administration: Coverage determinations are subject to the member's plan terms, exclusions, and limitations, and to state and federal requirements. This policy is a guide to medical necessity and not a guarantee of payment.
Documentation and coding guidance: Document the clinical indication(s) clearly in the medical record, including gestational age, specific reason for the exam, prior imaging findings prompting the study, and any findings addressed. Use current CPT descriptors and accurate ICD-10 diagnosis codes. Reference up-to-date professional coding guidance before claim submission. Inclusion or exclusion of codes in the policy does not guarantee coverage.
Provider documentation alignment: Providers should document indications and medical necessity consistent with this policy and applicable state/Medicare rules. Required clinical documentation may include prior preterm birth history, cervical length measurements and monitoring plan, transfer-of-care status, details supporting need for a detailed anatomic exam, and rationale for follow-up scans. Maintain imaging reports and measurements supportive of billed CPT codes.
Potential denial triggers: Subsequent standard first- or second/third-trimester ultrasounds beyond the allowed single exam per pregnancy (76801 or 76805) without documented medical necessity, repeat detailed anatomic ultrasounds (76811) without listed extenuating circumstances or appropriate diagnosis codes, scans performed solely for fetal sex or keepsake images, scans for growth evaluation performed <2 weeks apart, or ultrasounds to confirm pregnancy absent other indications are examples of services likely to be considered not medically necessary.
Includes fetal biometry and an anatomic survey used for anomaly screening, growth evaluation, presentation, amniotic fluid assessment, and placental location.
IndicationsUsed for screening for fetal anomalies, estimation of gestational age, evaluation of fetal growth, vaginal bleeding, cervical insufficiency, and other obstetric indications.
Detailed anatomic ultrasound (76811) — targeted detailed fetal anatomic exam for increased risk of anomaly
DefinitionDetailed anatomic ultrasound (CPT 76811) is a targeted, detailed fetal anatomic examination performed when there is increased risk of anomaly based on history, labs, or prior imaging.
Frequency guidanceGenerally limited to one exam per pregnancy per practice; a second detailed exam is appropriate only for extenuating circumstances such as referral to a new MFM practice, second opinion, or transfer to tertiary care.
Follow‑up codingWhen performing focused follow‑up of specific measurements or organ systems, use CPT 76816; CPT 76805 is used for general maternal‑fetal evaluation as appropriate.
Transvaginal ultrasound (TVU) — used for cervical length surveillance with frequency limits and clarified office setting guidance
Primary useTVU is used for cervical length surveillance, placenta location assessment (placenta previa), and when transabdominal imaging is inconclusive; first‑trimester indications mirror CPT 76801.
Frequency and maximumsCervical length screening per Table 1 with frequency and maximums (see TVU schedule); overall TVU limit up to 13 per pregnancy when performed in office.
Office setting clarificationPolicy clarifies that the TVU maximums apply when transvaginal ultrasounds are performed in an office setting.
Detailed Fetal Ultrasound — specialized second- or third-trimester anatomic evaluation with Table 4 diagnoses including O35.xx and A93.0 additions
DefinitionDetailed Fetal Ultrasound: specialized second‑ or third‑trimester anatomic evaluation supported by diagnosis codes listed in Table 4.
ICD‑10 additionsTable 4 was expanded to include numerous codes and ranges, specifically adding multiple O35.xx codes and A93.0.
Medical necessityMust be supported by one of the diagnosis codes/ranges listed in Table 4 to justify a first detailed fetal ultrasound; claims lacking these codes risk denial.
2022-06-21tvu_frequency_and_maximums_update
Updated Table 1 notes to increase TVU surveillance frequency (weekly for cervical length 25–29 mm) and revised TVU maximums: total allowed TVUS per pregnancy = 13 with maximums of 11 for prior preterm birth at 14–27 weeks and 9 for prior preterm birth at 28–36 weeks.
2022-03-22minor_clarification_and_table_removal
Removed erroneous Table 5 (diagnosis codes for TVU) and added the term 'detailed' to Section III to clarify further detailed anatomic ultrasounds; references reviewed and updated.
2011-01-11policy_creation_initial_approval
Policy created and reviewed by an obstetrical specialist; initial approval documented in the revision log.
The policy summary and revision notes identify several material updates and clarifications: expansion of ICD‑10 codes in Table 4 including additions of multiple O35.xx and A93.0 codes; timing adjustments and operationalized criteria in Table 1 (for example, the second‑trimester exam window and TVU scheduling); and added clarification about transfer‑of‑care circumstances and first‑trimester follow‑up for abnormally trending hCG levels.