CurrentBaylor Scott & White Health PlanPolicy 258

Fetal Surgery

Defines medical necessity criteria, coding, and prior authorization expectations for in-utero fetal surgical procedures for Baylor Scott & White Health Plan members across lines of business.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyFetal Surgery

Policy CodePolicy 258

Change TypeNo material clinical or coverage changes

Effective Date04/01/2025

Next Review Date03/10/2026

Key ActionVerify member plan benefits and obtain prior authorization when required for certain fetal surgery procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≈15indications listed

CPT/HCPCS/ICD-10code groups included

2019-2025revision history

Coverage Criteria for In-Utero Fetal Surgery

Medically Necessary Indications

BSWHP may consider in-utero fetal surgery medically necessary for any of the following indications:

Medically necessary indications: Fetoscopic occlusion of anastomotic vessels in early, severe twin-twin transfusion (e.g., twin reversed arterial perfusion [TRAP]); ablation of anastomotic vessels in acardiac twins; insertion of pleuro-amniotic shunt for fetal pleural effusion; removal of sacrococcygeal teratoma; fetal vesico-amniotic shunt procedures for fetal urinary-tract obstruction; repair of myelomeningocele; congenital cystic adenomatoid malformation; resection of malformed pulmonary tissue; extralobar pulmonary sequestration.

Each indication requires appropriate multidisciplinary care and plan-level coverage verification.

Experimental / Investigational / Unproven

BSWHP considers the following applications experimental, investigational and unproven:

Experimental/unproven indications: Fetal aortic valvuloplasty; shunting for the treatment of fetal cerebral ventriculomegaly; treatment of congenital diaphragmatic hernia; treatment of amniotic band syndrome; treatment of cleft lip and/or cleft palate; treatment of aqueductal stenosis (hydrocephalus); treatment of congenital heart disease (e.g., mitral valve dysplasia); treatment of gastroschisis; treatment of fetal hydronephrosis; in-utero stem cell transplantation and in-utero gene therapy; all other applications of in-utero surgery.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyFetal Surgery

Policy CodePolicy 258

Change TypeNo material clinical or coverage changes

Effective Date04/01/2025

Next Review Date03/10/2026

Key ActionVerify member plan benefits and obtain prior authorization when required for certain fetal surgery procedures.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding — CPT, HCPCS, and ICD-10

Covered CPT CodesCPTCovered

59072	Fetal umbilical cord occlusion, including ultrasound guidance
59074	including ultrasound guidance
59076	Fetal shunt placement; including ultrasound guidance
59897	Unlisted fetal invasive procedure, including ultrasound guidance, when performed

Covered HCPCS CodesHCPCSCovered

S2401	Repair, urinary tract obstruction in the fetus, procedure performed in-utero
S2402	Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in-utero
S2403	Repair, extralobar pulmonary sequestration in the fetus, procedure performed in-utero
S2404	Repair; myelomeningocele in the fetus, procedure performed in-utero
S2405	Repair of sacrococcygeal teratoma in the fetus, procedure performed in-utero
S2409	Repair, congenital malformation of fetus, procedure performed in-utero, not otherwise classified
S2411	Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome

HCPCS Not CoveredHCPCSNot Covered

S2400

Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in-utero

ICD-10 CodesICD-10

033.7xx0	Maternal care for disproportion due to other fetal deformities, not applicable or unspecified
033.7xxx	Maternal care for disproportion due to other fetal deformities, fetus X
036.21x0	Maternal care for hydrops fetalis, first trimester, not applicable or unspecified
036.21xX	Maternal care for hydrops fetalis, first trimester, fetus X
036.22x0	Maternal care for hydrops fetalis, second trimester, not applicable or unspecified
036.23x0	Maternal care for hydrops fetalis, third trimester, not applicable or unspecified
036.23xX	Maternal care for hydrops fetalis, third trimester, fetus X
043.021	Fetus-to-fetus placental transfusion syndrome, first trimester
043.022	Fetus-to-fetus placental transfusion syndrome, second trimester
043.023	Fetus-to-fetus placental transfusion syndrome, third trimester

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Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required for Certain Fetal Surgery Procedures — Verify coverage and obtain prior authorization when required. Certain in-utero fetal surgery procedures require prior authorization from Baylor Scott & White Health Plan before scheduling or performing services.

Providers must obtain prior authorization when required by the plan for fetal surgery procedures.
Check member-specific benefit coverage and prior authorization requirements prior to providing services.

Billing Rule

Provider Action / Billing Note

Actionable provider-facing billing note: confirm prior authorization determination and follow billing/coding guidance per the plan.

Obtain and document prior authorization number when required.
Include clinical justification and relevant supporting records with the prior authorization request.

Documentation Required

Provider Guidance

Providers must review the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD) for coverage details and any plan-specific limitations or exclusions. Medical necessity determinations per this policy do not guarantee coverage — final coverage is subject to the member's benefit plan document and any applicable federal or state mandates.

Verify member eligibility and specific benefit limits in the EOC/SPD before scheduling fetal surgery.
For Medicare and Medicaid members, confirm applicable NCD/LCD or state Medicaid rules; if none apply, use this policy's medical necessity criteria as guidance.

Denial Risk

Provider Warning: Coverage vs Medical Necessity

Medical necessity does not ensure benefit coverage. Absence of a controlling federal or state mandate or lack of a plan benefit may limit coverage — providers should not assume payment based solely on medical necessity.

If the member's plan excludes the service or an applicable mandate is absent, the service may not be covered even if medically necessary.
When coverage is uncertain, obtain prior authorization and pre-service determination to reduce denial risk.

Background

Intrauterine fetal surgery involves accessing the fetus through the uterine wall using either open or minimally invasive (fetoscopic) techniques to correct fetal abnormalities and then close the uterus to allow continued gestation. These procedures are performed for fetal anomalies that threaten organ development or survival and typically require a coordinated, multidisciplinary team and appropriate neonatal resources.

Because of the complexity and potential maternal–fetal risks, candidates for fetal surgery should be managed by specialized teams with expertise in maternal–fetal medicine, pediatric surgery, neonatology, and high‑level obstetric and neonatal intensive care (e.g., a Level III NICU). Clinical decision‑making must balance potential fetal benefit against maternal risk and consider plan benefit verification and authorization requirements.

Definitions

Intrauterine fetal surgery — definition and brief explanatory fields

TermIntrauterine fetal surgery

DefinitionAccessing the fetus through the uterine wall (open or minimally invasive endoscopic technique) to surgically correct fetal abnormalities and close the uterus to permit completion of gestation

PurposeRepair fetal anomalies that interfere with organ development or threaten fetal survival

Team and setting requirementsRequires a multidisciplinary team (pediatric surgeons, perinatal obstetricians, sonographers, echocardiographers, neonatologists, intensive care specialists, geneticists, ethicists, and specialized nursing) and availability of a Level III NICU and high-level obstetric care

TechniquesIncludes open fetal surgery and minimally invasive (fetoscopic/endoscopic) approaches