CurrentBlue Cross Blue Shield - MassachusettsPolicy 007

Obstetrical Ultrasound & Ultrasound for Family Planning

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Defines medical necessity and coverage criteria for obstetrical ultrasound across trimesters and for ultrasound related to intrauterine device (IUD) placement and family planning; applies to Commercial members (HMO, POS, PPO, Indemnity) of Blue Cross Blue Shield - Massachusetts.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyObstetrical Ultrasound & Ultrasound for Family Planning

Policy CodePolicy 007

Change TypeAnnual review — no material changes

Effective DateNov 1, 2024

Last ReviewNov 1, 2024

Next Review DateNov 1, 2024

Key ActionObtain precertification/preauthorization for inpatient services described in this policy; outpatient prior authorization is not required for Commercial products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentBlue Cross Blue Shield - MassachusettsPolicy 007

Obstetrical Ultrasound & Ultrasound for Family Planning

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Massachusetts Policy 007 alerts

Get alerted when Policy 007 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyObstetrical Ultrasound & Ultrasound for Family Planning

Policy CodePolicy 007

Change TypeAnnual review — no material changes

Effective DateNov 1, 2024

Last ReviewNov 1, 2024

Next Review DateNov 1, 2024

Key ActionObtain precertification/preauthorization for inpatient services described in this policy; outpatient prior authorization is not required for Commercial products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Coverage Criteria for Obstetrical and Family Planning Ultrasound

Medically Necessary Obstetrical Ultrasound Indications

Covered when ANY of the following trimester-specific routine indications or listed clinical indications are present for Commercial members (HMO, POS, PPO, Indemnity):

Trimester routine scans: First trimester: one routine ultrasound to confirm intrauterine pregnancy and estimate gestational age. Second trimester: one routine ultrasound (generally 18-20 weeks) to survey fetal anatomy and generate an accurate estimation of gestational age. Third trimester: one routine ultrasound to determine fetal presentation or to evaluate fetal condition in late registrants for prenatal care.

Additional indicated reasons: Includes abnormal fetal heart rate; abrupted placenta; adjunct to amniocentesis, chorionic villus sampling, embryo transfer, or other procedure; adjunct to cervical cerclage placement; adjunct to external cephalic version; advanced maternal age (≥35 years); antepartum hemorrhage; assessment of cervical length as an indicator of preterm delivery; confirm cardiac activity; congenital malformation; decreased fetal movement; elevated maternal alpha-fetoprotein; estimation of gestational age; evaluation of maternal pelvic or adnexal masses or uterine abnormalities; evaluation of pelvic or abdominal pain; evaluation of abnormal biochemical markers; evaluation of cervical insufficiency; evaluation of fetal growth or fetal well-being; follow-up evaluation of a fetal anomaly; history of previous congenital anomaly; isoimmunization (Rh) resulting fetal disease; liver disorders in pregnancy; maternal injury affecting fetus or newborn; maternal risk factors (e.g., family history of congenital anomalies, chronic systemic disease, substance abuse); obesity complicating pregnancy; other placental conditions (including placenta previa, placental infarct); polyhydramnios/oligohydramnios; post-term or prolonged pregnancy (>41 weeks); premature rupture of membranes; preterm delivery indicator; renal disease; Rh incompatibility; screen for fetal aneuploidy or anomalies; significant uterine size/date discrepancy; small for gestational dates; spontaneous or threatened abortion or missed abortion; spotting or vaginal bleeding; suspected abnormal presentation; suspected amniotic fluid abnormalities; suspected anatomical uterine abnormality; suspected ectopic pregnancy; suspected fetal death; suspected fetal growth abnormality (IUGR or macrosomia); suspected hydatidiform mole; suspected multiple gestation; suspected uterine abnormalities; vasa previa; velamentous cord insertion; and other indications listed in policy.

Family Planning / IUD-related ultrasound

Covered when specific clinical indications are present:

IUD complications: Ultrasound to evaluate complications of IUD placement such as pain or excess bleeding is considered MEDICALLY NECESSARY.

Routine IUD placement check: Routine ultrasound to check placement of an IUD is NOT MEDICALLY NECESSARY.

See 'Not Medically Necessary' section and policy history for prior clarifications.

The policy identifies specific situations that are not medically necessary. Notably, more than one complete obstetrical ultrasound in a routine pregnancy is considered NOT MEDICALLY NECESSARY. Routine ultrasounds performed solely to check for intrauterine device (IUD) placement are also listed as NOT MEDICALLY NECESSARY. These determinations distinguish routine surveillance imaging from targeted, indication-driven exams and align noncoverage with repeated complete OB ultrasounds in an otherwise uncomplicated pregnancy.

Within the provided source chunks there are no explicit exclusions beyond the not medically necessary items already stated; the policy history and related notes do not add additional exclusion clauses in these excerpts. For Medicare local and national coverage details readers are referred to MP #132 as noted in the policy history.

The policy reiterates that certain routine uses of ultrasound are not medically necessary. Specifically, it states that more than one complete obstetrical ultrasound in a routine pregnancy is NOT MEDICALLY NECESSARY and that routine ultrasound to check for IUD placement is NOT MEDICALLY NECESSARY. By contrast, ultrasound to evaluate placenta or fetal well-being is covered when clinical indications exist (see medically necessary criteria).

The document excerpts do not contain an explicit blanket exclusion for all IUD-related ultrasound; rather they clarify coverage by indication. The policy specifies that ultrasound to check for complications of IUD placement (for example, pain or excess bleeding) is MEDICALLY NECESSARY, while a routine ultrasound solely to confirm IUD placement is NOT MEDICALLY NECESSARY. The policy history documents that medically necessary and not medically necessary language for IUD-related ultrasound was added and clarified in prior revisions.

Coding

CPT Codes (selected from policy text)CPT

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
76816	Ultrasound, pregnant uterus, real time with image documentation, transvaginal
76817	Ultrasound, pregnant uterus, real time with image documentation, after first trimester (≥ 14 weeks 0 days), transabdominal approach; single or first gestation
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
76856	Ultrasound, pelvic (nonobstetric), real time with image documentation; complete

No explicit CPT/HCPCS/ICD codes in these chunksmixed

No codes listed

Coding — none in this section

Coding thresholdsNone stated in this section.

Related coding guidanceProviders should report services using current procedure, revenue, and diagnosis codes; inclusion of a code in the policy does not by itself determine coverage.

See alsoRefer to CPT code list in Coding section for procedure-level codes.

Provider Actions and Authorization

Prior Authorization

Precertification/Preauthorization requirements

For services described in this policy, precertification/preauthorization is required when the procedure is performed inpatient; outpatient prior authorization is not required for Commercial Managed Care (HMO and POS), Commercial PPO, and Indemnity.

Inpatient procedures: precertification/preauthorization IS REQUIRED for all products when performed inpatient.
Outpatient procedures: Prior authorization is not required for Commercial Managed Care (HMO and POS), Commercial PPO, and Indemnity.

Prior Authorization

Prior authorization / LCD/NCD reference

Medicare-specific references were removed from this policy; for local and national coverage determinations refer to MP #132 (Medicare Advantage Management). This section does not state additional Medicare prior authorization requirements.

See MP #132 for local coverage determination (LCD) and national coverage determination (NCD) references following removal of Medicare information (1/2023).

Background

Ultrasound uses high-frequency sound waves transmitted into tissues with returning echoes captured by a transducer to generate real-time images for clinical interpretation. In obstetrics, common uses include dating the pregnancy (first trimester), a second-trimester anatomy survey (generally 18–20 weeks), assessment of fetal presentation later in pregnancy, and evaluation of fetal well-being or growth. Imaging may be performed transabdominally or transvaginally depending on gestational age and clinical indication, and frequencies commonly used in OB/GYN ultrasound range around 2–5 MHz.

Definitions and References

Ultrasound — definition and common OB/GYN frequencies

DefinitionUltrasound is the transmission of high-frequency sound waves through tissues of varying densities; echoes produced at tissue interfaces are detected by piezoelectric crystals in a transducer and displayed as images on a monitor.

TransducerHand-held device passed over the abdominal surface (transabdominal) or used transvaginally depending on gestation and indication.

Common OB/GYN frequencies2-5 MHz are the most common frequencies of sound waves used in OB/GYN ultrasound.

Clinical usesUsed to image fetal and maternal structures for dating, anatomic survey, presentation, and assessment of fetal well-being.

Primary clinical reference — ACOG Practice Bulletin No. 175

Title and source

Revision History

2024-11-01Annual reviewLatest

Annual policy review: description, summary, and references reviewed; policy statements clarified.

2023-09Annual review

Annual policy review: no new updates from ACOG Practice Bulletin No. 175: Ultrasound in Pregnancy.

2023-01Content removal

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyObstetrical Ultrasound & Ultrasound for Family Planning

Policy CodePolicy 007

Change TypeAnnual review — no material changes

Effective DateNov 1, 2024

Last ReviewNov 1, 2024

Next Review DateNov 1, 2024

Key ActionObtain precertification/preauthorization for inpatient services described in this policy; outpatient prior authorization is not required for Commercial products.

SourceLink

On This Page

Note

Provider action summary (preserved unlabeled item)

Providers must follow the policy’s prior authorization and coding instructions as stated; no additional unnamed provider-action requirements are specified in these sections.

Adhere to inpatient precertification requirements and outpatient prior authorization rules as applicable.
Follow coding and documentation guidance when submitting claims (see coding block).

Step Therapy

Step therapy requirements

There are no step therapy requirements mentioned in the policy sections reviewed.

No step therapy rules are specified for obstetrical or family planning ultrasound in the cited policy history and sections.

Documentation Required

Coding and documentation guidance

Report services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable; inclusion or exclusion of a code in the policy does not by itself determine coverage or reimbursement.

Use current CPT/HCPCS and ICD codes and appropriate modifiers when billing.
Verify member contract benefits to determine coverage or non-coverage for an individual member.

Note

Policy history and clarifications

Policy history documents clarifications relevant to provider actions, including addition of medically necessary language for IUD-related ultrasound and the removal of Medicare information directing readers to MP #132.

1/2017: Title changed and medically necessary/not medically necessary language added for ultrasound related to IUD placement.
1/2023: Medicare information removed; see MP #132 for LCD/NCD.

Prior Authorization

Prior authorization rules

Reinforces that precertification/preauthorization is required for inpatient services described in this policy and that outpatient prior authorization is not required for routine commercial outpatient ultrasound for Commercial Managed Care (HMO and POS), PPO, and Indemnity.

Obtain inpatient precertification/preauthorization for procedures performed inpatient as described in the policy.
Outpatient routine ultrasound for Commercial products generally does not require prior authorization.

Denial Risk

Denial triggers not specified

No explicit denial triggers are listed in the cited sections of the policy.

The document sections reviewed do not identify specific actions or circumstances that will automatically result in denial beyond the requirement to meet the medical necessity criteria and inpatient precertification rules.

Role in policyCited as the primary clinical reference informing medically necessary indications in this policy (see policy history: additions and reviews referencing the Bulletin).

Medicare information removed; readers referred to MP #132 for local and national coverage determinations.

2022-06Annual review

Annual policy review: no new updates from ACOG Practice Bulletin No. 175: Ultrasound in Pregnancy.

2018-02-01Clinical update

New medically necessary indications from ACOG Practice Bulletin No. 175: Ultrasound in Pregnancy were added.

2017-01-01Title change and content update

Title changed to 'Obstetrical Ultrasound & Ultrasound for Family Planning'; medically necessary and not medically necessary language added for IUD-related ultrasound and coding information was clarified.

2015-09-01Coverage clarification

Coverage clarified based on ACOG guidelines; formatting, editing, and coding updates performed.