CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Pregnancy termination (medical and surgical abortion)

This policy governs coverage, payment, billing, and clinical requirements for pregnancy termination (medical and surgical abortion) as an enhanced Medicare Advantage benefit for members of the University of Michigan Medicare Plus Blue Group PPO plan.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPregnancy termination (medical and surgical abortion)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionDocument confirmation of pregnancy, verified gestational age, fulfill all legal requirements, provide 14-day follow-up instructions and 24-hour emergency contact information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MultipleProcedure codes included

ExcludedElective procedures

No restrictionsFrequency limits

Cost shareMember responsibility

11/25/2025Approval date

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Coverage and Medical Necessity

Medically necessary and enhanced-benefit coverage criteria

Covered when meeting Original Medicare medically necessary criteria and payer conditions:

Medicare medically necessary indications: Original Medicare coverage applies when pregnancy results from rape or incest, or when the woman has a physical disorder, injury, or illness (including a life‑endangering physical condition caused by the pregnancy) certified by a physician that would place her in danger of death unless abortion is performed.

Source: Original Medicare rules applied by Medicare Plus Blue.

Enhanced benefit selection: Coverage for pregnancy terminations (medical and surgical) is provided as an enhanced benefit to members of the University of Michigan Medicare Plus Blue Group PPO plan; scope, reimbursement, and member cost sharing are determined by the group that selects the benefit.

Elective abortions are excluded unless the group offers the benefit via an optional rider.

Administrative and clinical prerequisites: Confirmation of pregnancy, verified gestational age, fulfillment of all applicable legal requirements, provider instructions for follow‑up within 14 days and 24‑hour emergency contact information; medication administration should follow National Abortion Federation guidance.

Documentation required on claim submission; follow Original Medicare guidance for medically necessary terminations.

Coding and payment conditions: Services billed with CPT/HCPCS codes 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, S0190, S0191, S0199, S2260, S2265, S2266, S2267 are payable consistent with Original Medicare when medically necessary; these codes are restricted when billed for elective or voluntary procedures (not paired with a medically necessary diagnosis).

Frequency and age restrictions: none.

Coverage for elective or voluntary abortions is excluded under the standard plan unless the employer/group selects the optional rider that provides this benefit. The policy explicitly states that "coverage of elective abortions, both medically and surgically induced, are considered an exclusion unless the benefit is offered through an optional rider." Codes that are restricted when billed for elective/voluntary indications include 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, S0190, S0191, S0199, S2260, S2265, S2266, S2267 (these should not be paid for elective diagnoses unless the group benefit includes the rider).

This policy aligns coverage determinations with Original Medicare for medically necessary pregnancy terminations. Services that do not meet Original Medicare's medically necessary criteria (for example, terminations not meeting the conditions such as pregnancy resulting from rape or incest or where a certified physician documents a life‑threatening condition) are not covered under the standard benefit. For medically necessary terminations, providers should reference Original Medicare guidance and follow the payer's administrative requirements for documentation and claims processing.

Procedure and Diagnosis Coding

Covered CPT Codes (surgical/medical procedures)CPTCovered

59840	Induced abortion, by dilation and curettage.
59841	Induced abortion, by dilation and evacuation.
59850	Induced abortion, by 1 or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines.
59851	Induced abortion by 1 or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or evacuation.
59852	Induced abortion, by 1 or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines; with hysterotomy (failed intra-amniotic injection).
59855	Induced abortion, by 1 or more vaginal suppositories (e.g., prostaglandin) with or without cervical dilation (e.g., laminaria), including hospital admission and visits, delivery of fetus and secundines.
59856	Induced abortion, by 1 or more vaginal suppositories (e.g., prostaglandin) with or without cervical dilation (e.g., laminaria), including hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or evacuation.

Covered HCPCS/S-codes and relatedHCPCSCovered

59857	Induced abortion, by 1 or more vaginal suppositories (e.g., prostaglandin) with or without cervical dilation (e.g., laminaria), including hospital admission and visits, delivery of fetus and secundines; with hysterotomy (failed medical evacuation).
S0190	Mifepristone, oral, 200 mg.
S0191	Misoprostol, oral, 200 mcg.
S0199	Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion) except drugs.
S2260	Induced abortion, 17 to 24 weeks.
S2265	Induced abortion, 25 to 28 weeks.
S2266	Induced abortion, 29 to 31 weeks.
S2267	Induced abortion, 32 weeks or greater.

Diagnosis coding guidanceICD-10

ICD-10

No specific ICD-10 restrictions listed; diagnosis codes should be reported to highest specificity.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Coverage follows Original Medicare guidance for medically necessary pregnancy terminations. When prior authorization is required by the member's plan or by Blue Cross Blue Shield - Michigan, providers must obtain prior authorization before scheduling services. Failure to obtain required prior authorization may result in claim denial or member liability.

Affected codes when elective/voluntary and not paired with a medically necessary diagnosis: 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, S0190, S0191, S0199, S2260, S2265, S2266, S2267
Prior authorization applies when specified by the member's Medicare Advantage PPO plan or Blue Cross plan rules

Documentation Required

Clinical Administration Guidance

Medical abortion medication administration must follow the National Abortion Federation guidelines. Providers should ensure administration, counseling, follow-up instructions, and emergency contact information comply with those standards and with applicable Michigan law.

Policy Background

Pregnancy termination refers to the removal of pregnancy tissue or products of conception from the uterus and encompasses both medical and surgical methods. The policy notes that the term "fetus and placenta" is generally applied after approximately eight weeks' gestation and that the benefit covers medical abortion, surgical abortion, and labor‑inducing abortion as described in the policy.

Key Definitions

Definitions — pregnancy termination

TermPregnancy termination

DefinitionRemoval of pregnancy tissue, products of conception or the fetus and placenta (afterbirth) from the uterus.

Gestational terminologyThe terms 'fetus' and 'placenta' are generally used after eight weeks of pregnancy.

Included proceduresIncludes medical abortion, surgical abortion, and labor‑inducing abortion.