Blue Cross Blue Shield MA Obstetrical Ultrasound Coverage

Coverage Criteria — Obstetrical and Family Planning Ultrasound

Routine obstetrical ultrasound

Routine ultrasounds in normal-risk pregnancy are COVERED when the following timing-based criteria are met:

First trimester routine: One routine ultrasound during the first trimester is medically necessary to estimate gestational age and confirm intrauterine pregnancy.first trimester (<14 weeks)

Second trimester routine: One routine ultrasound in the second trimester (generally between 18-20 weeks) is medically necessary to survey fetal anatomy and generate an accurate estimation of gestational age.~18-20 weeks

Third trimester routine indications: One routine ultrasound in the third trimester is medically necessary for specific indications including evaluation of fetal condition in late registrants for prenatal care and to determine fetal presentation.third trimester as indicated

Indicated (non-routine) obstetrical ultrasound

Ultrasounds may also be MEDICALLY NECESSARY for specific clinical indications including, but not limited to:

Indications list: Abnormal fetal heart rate; abruption; adjunct to cervical cerclage placement; adjunct to amniocentesis, chorionic villus sampling, embryo transfer, or other invasive procedures; adjunct to external cephalic version; antepartum hemorrhage; advanced maternal age (>=35); assessment of cervical length for preterm delivery risk; confirmation of cardiac activity; chronic systemic disease (eg, hypertension, diabetes, sickle cell disease); congenital malformation (fetal or maternal); decreased fetal movement; elevated maternal alpha-fetoprotein; evaluation of fetal growth or fetal well-being; evaluation of pelvic or abdominal pain or pelvic mass; estimation of gestational age; follow-up evaluation of a fetal anomaly; isoimmunization (Rh) resulting in fetal disease; maternal injury affecting fetus; placenta previa; polyhydramnios or oligohydramnios; premature rupture of membranes; prolonged or post-term pregnancy; pre-term delivery indicators; renal disease; Rh incompatibility; screening for fetal aneuploidy or fetal anomalies; significant discrepancy between uterine size and dates; suspected amniotic fluid abnormalities; suspected abnormal presentation; suspected fetal death; suspected ectopic pregnancy; suspected multiple gestation; suspected hydatidiform mole; suspected uterine anatomical abnormality; vaginal bleeding or spotting; vasa previa; velamentous cord insertion; obesity complicating pregnancy; and other placental conditions or complications (see policy).clinical indication present

Full list reflected from policy chunks 3-4.

Ultrasound for family planning (IUD)

Family planning ultrasound coverage stance:

IUD placement: Routine ultrasound to check for placement of an intrauterine device (IUD) is NOT MEDICALLY NECESSARY. Ultrasound to evaluate complications of IUD placement (for example, persistent pain or excess bleeding) is MEDICALLY NECESSARY.complication present vs routine placement

The policy excludes routine imaging solely to confirm IUD placement. Specifically, routine ultrasound to check for placement of an IUD is NOT MEDICALLY NECESSARY; however, ultrasound to evaluate for complications such as pain or abnormal bleeding after IUD placement is considered MEDICALLY NECESSARY and may be covered when clinically indicated. Additionally, the policy states that more than one complete obstetrical ultrasound in a routine pregnancy is considered NOT MEDICALLY NECESSARY and may be denied.

Emphasis: multiple full anatomy or complete obstetrical ultrasounds performed for routine monitoring in an otherwise normal-risk pregnancy exceed the coverage position. The policy explicitly notes that more than one complete obstetrical ultrasound in a routine pregnancy is NOT MEDICALLY NECESSARY. Likewise, routine post–IUD placement scanning is excluded—only imaging for suspected complications (eg, pain, excess bleeding) meets medical necessity criteria.

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization Required for Inpatient Services

Precertification/Preauthorization is REQUIRED for services described in this policy when performed inpatient. Failure to obtain required precertification for inpatient procedures may result in denial of payment or claim delay.

Applicable to all products when performed inpatient.
Members and providers should confirm authorization requirements and obtain prior approval before admission.

Prior Authorization

Outpatient Prior Authorization May Be Required

For outpatient services, prior authorization requirements vary by product. Check product-specific rules before scheduling outpatient imaging.

Commercial Managed Care (HMO and POS): prior authorization may be required for outpatient services — verify with plan.
Commercial PPO and Indemnity: prior authorization requirements may differ — verify with plan.

CPT and Procedure Codes

Covered CPT Codes (selected list)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.
76802	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days) , transabdominal approach; each additional gestation (List separately in addition to code for primary procedure).
76805	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_

Additional CPT CodesCPTCovered

76810	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 (List separately_in addition to code for primary procedure).
76811	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation.
76812	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (List separately_in addition to code for primary procedure_.
76815	Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat; placental location, fetal position andlor qualitative amniotic fluid volume); 1 or more fetuses.
76816	Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re- evaluation 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.
76817	Ultrasound,_pregnant uterus,_real time with image documentation,_transvaginal.
76818	Fetal biophysical profile;_with non-stress testing.
76819	Fetal biophysical profile;_without non-stress testing.
76830	Ultrasound,transvaginal.
76831	Saline _infusion sonohysterography_ SIS)including_color flow Doppler_when performed.

1–10 of 12

1/2

Definitions

Complete obstetrical ultrasound — definition and key characteristics

DefinitionReal-time ultrasound with image documentation for fetal and maternal evaluation using transabdominal or transvaginal approach (applicable in first trimester and after first trimester).

ApproachesTransabdominal and transvaginal approaches are used depending on gestational age and clinical question; CPT descriptors include both transabdominal (76801, 76802, 76805–76816) and transvaginal codes (76817, 76830).

Timing/UsePerformed in first trimester (<14 weeks 0 days) for dating and confirmation (CPT 76801/76802) and after first trimester (≥14 weeks 0 days) for anatomy and growth assessment (CPT 76805 and related codes).

Image documentationRequires real-time scanning with image documentation as specified in the CPT code descriptions (eg, ‘real time with image documentation, fetal and maternal evaluation’).

ScopeIncludes complete obstetrical exams (detailed anatomic examination 76811/76812), limited exams (76815), follow-up scans (76816), and biophysical profiles (76818/76819) when clinically indicated.

Background

Ultrasound uses high-frequency sound waves to visualize the pregnant uterus and fetal structures. In obstetrics, transabdominal and transvaginal approaches are used depending on gestational age and the clinical question; typical probe frequencies fall in the range commonly used for obstetrical imaging. Routine timing for medically necessary scans in a normal-risk pregnancy are: one first trimester scan (<14 weeks) to estimate gestational age and confirm intrauterine pregnancy, one second trimester anatomy survey (approximately 18–20 weeks), and selective third trimester scans when clinically indicated (for example to assess fetal presentation or late-entry registrants).

OpenPayer

Obstetrical Ultrasound Coverage Criteria

Coverage Criteria — Obstetrical and Family Planning Ultrasound

Provider Actions, Authorization & Documentation

CPT and Procedure Codes

Definitions

Background