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    v1.0.28
    OpenPayerPolicy UpdatesObstetrics/GynecologyBaylor Scott & White Fetal Surgery Coverage | Open…
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    CurrentBaylor Scott & White Health PlanPolicy 258

    Fetal Surgery

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    This policy governs coverage and medical necessity criteria for in-utero fetal surgical procedures for Baylor Scott & White Health Plan members across lines of business; providers should also consult member-specific Evidence of Coverage or Summary Plan Description for benefit details.

    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyFetal Surgery
    Policy CodePolicy 258
    Change TypeRoutine review — no material changes
    Effective DateApr 1, 2026
    Last ReviewMar 26, 2026
    Next Review DateApr 26, 2027
    Key ActionObtain prior authorization and confirm member benefit coverage per the plan Evidence of Coverage before performing in‑utero fetal surgery.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    11+
    Medically necessary indications
    12+Experimental/investigational
    4 listedCPT codes
    8 listedHCPCS codes
    2026-03-26Last review

    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: Ablation of anastomotic vessels in acardiac twins; Fetoscopic occlusion of anastomotic vessels in early, severe twin-twin transfusion (e.g., twin reversed arterial perfusion [TRAP]); Insertion of pleuro-amniotic shunt for fetal pleural effusion; Fetal vesico-amniotic shunt procedures for fetal urinary-tract obstruction; Removal of sacrococcygeal teratoma; Repair of myelomeningocele; Resection of malformed pulmonary tissue; Congenital cystic adenomatoid malformation; Extralobar pulmonary sequestration.

    Each listed indication is an individually acceptable reason for considering in-utero surgery per policy.

    Experimental / Investigational (Not Covered)

    BSWHP considers the following applications of in-utero fetal surgery experimental, investigational and unproven because effectiveness has not been established:

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

    These applications are considered unproven and not covered per policy.

    All applications of in‑utero fetal surgery that are not specifically listed as medically necessary in this policy are considered experimental, investigational and unproven. Such applications lack sufficient evidence of established effectiveness and therefore are not supported for coverage under this policy.

    The policy lists HCPCS S2400 (Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in‑utero) as Not Covered.

    Procedures identified on the policy’s Experimental/Investigational (Not Covered) list are considered not medically necessary due to lack of established effectiveness. When a procedure is categorized as experimental/investigational under this policy, it is not supported for coverage and may be denied when billed.

    Coding and Billing Codes

    CPT CodesCPT
    59072Fetal umbilical cord occlusion, including ultrasound guidance
    59074Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance
    59076Fetal shunt placement, including ultrasound guidance
    59897Unlisted fetal invasive procedure, including ultrasound guidance, when performed
    HCPCS Codes (listed; S2400 noted as Not Covered)HCPCS
    S2401Repair, urinary tract obstruction in the fetus, procedure performed in-utero
    S2402Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in-utero
    S2403Repair, extralobar pulmonary sequestration in the fetus, procedure performed in-utero
    S2404Repair, myelomeningocele in the fetus, procedure performed in-utero
    S2405Repair of sacrococcygeal teratoma in the fetus, procedure performed in-utero
    S2409Repair, congenital malformation of fetus, procedure performed in-utero, not otherwise classified
    S2411Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome
    S2400Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in-utero (Not Covered)
    ICD-10 CodesICD-10
    O33.7xx0 / O33.7xxxMaternal care for disproportion due to other fetal deformities
    O36.21x0 / O36.21xxMaternal care for hydrops fetalis, first trimester
    O36.22x0Maternal care for hydrops fetalis, second trimester
    O36.23x0 / O36.23xxMaternal care for hydrops fetalis, third trimester
    O43.021 / O43.022 / O43.023 / O43.029Fetus-to-fetus placental transfusion syndrome (twin-to-twin transfusion syndrome) by trimester or unspecified

    Provider Actions and Requirements

    Prior Authorization

    Prior Authorization Required

    Providers must obtain prior authorization before scheduling fetal surgery. Verify member eligibility and benefits and secure authorization per the plan's prior authorization process.

    • Applies to all fetal surgery procedures described in this policy
    • Confirm benefit coverage in the member's EOC/SPD before authorization request
    Note

    Provider action and coordination

    Providers should follow the steps below as part of the authorization and care coordination process.

    • Coordinate multidisciplinary evaluation (see documentation callout)
    • Ensure availability of Level III NICU and high-level obstetric care at the treating facility
    • Document plan for maternal and neonatal follow-up and delivery location

    Background

    Intrauterine fetal surgery refers to accessing the fetus through the uterine wall using either open surgical or minimally invasive endoscopic (fetoscopic) techniques to correct congenital anomalies and then close the uterus to allow continued gestation. These procedures are performed by a multidisciplinary team and generally require availability of a Level III neonatal intensive care unit and high‑level obstetric services. Indications for in‑utero surgery are limited and selected when the intervention has a reasonable prospect of improving fetal outcome; many other applications remain investigational.

    Definitions

    Intrauterine fetal surgery — definition
    DefinitionAccessing the fetus through the uterine wall using open or minimally invasive endoscopic techniques to surgically correct fetal abnormalities and close the uterus to permit continued gestation.
    PurposeSurgically correct congenital anomalies that interfere with fetal organ development or threaten fetal survival.
    Approach typesOpen fetal surgery (hysterotomy) or minimally invasive fetoscopic endoscopic techniques.
    Clinical requirementsPerformed by a multidisciplinary team with availability of Level III NICU and high-level obstetric care.
    ScopeEncompasses a broad range of highly complex intrauterine interventions to repair birth defects prior to delivery.
    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyFetal Surgery
    Policy CodePolicy 258
    Change TypeRoutine review — no material changes
    Effective DateApr 1, 2026
    Last ReviewMar 26, 2026
    Next Review DateApr 26, 2027
    Key ActionObtain prior authorization and confirm member benefit coverage per the plan Evidence of Coverage before performing in‑utero fetal surgery.
    SourceLink
    On This Page
    Coverage Criteria for In‑utero Fetal SurgeryCoding and Billing CodesProvider Actions and RequirementsBackgroundDefinitions
    Documentation Required

    Required clinical documentation

    Comprehensive clinical documentation must be submitted with the prior authorization request to support medical necessity.

    • Multidisciplinary assessment documenting fetal diagnosis, severity, and prognosis
    • Indication for fetal surgery with rationale why in-utero intervention is required rather than postnatal care
    • Documentation of fetal imaging and diagnostic studies (e.g., ultrasound, MRI, echocardiography)
    • Operative plan including approach (open vs. minimally invasive), anticipated risks, and expected benefits
    • Evidence of facility capability: confirmation of Level III NICU and high-level obstetric care availability
    • Maternal informed consent and counseling notes including risks to mother and fetus
    • Plan for neonatal care, including anticipated need for specialized neonatal surgery and postnatal care
    Denial Risk

    Denial risk for non-medically necessary services

    Services that do not meet the policy's medical necessity criteria or are excluded by the member's Evidence of Coverage/Summary Plan Description may be denied.

    • Requests lacking required clinical documentation may be denied as not medically necessary
    • Procedures performed at facilities without required Level III NICU or appropriate obstetric support risk denial
    • Coverage is subject to the member's plan benefits — medical necessity determination does not guarantee coverage