CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment

Defines medical necessity and coverage stance for first-trimester Down syndrome screening that incorporates maternal serum markers and fetal ultrasound markers (nuchal translucency and fetal nasal bone) for pregnant individuals in the first trimester. Specifies coverage differences for combined screening versus NT alone and nasal bone assessment, and lists applicable CPT codes.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyFirst-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment

Policy CodePolicy N/A

Change Typeclarified

Effective DateNov 17, 2005

Next Review Date

Key ActionProvider must ensure the woman is adequately counseled and desires information on Down syndrome risk prior to performing combined first-trimester screening; counseling is a coverage condition.

SourceLink

POLICY UPDATE CHANGES

Policy last updated 02/16/2023; published provider updates through April 2023 are listed.

1Covered combined screening modality

2Not covered: NT alone and nasal bone assessment

2Relevant gestational windows (NT; nasal bone)

Coverage Summary

Overview: This policy (effective 11/17/2005; last reviewed 02/16/2023) defines coverage for first‑trimester Down syndrome screening that combines fetal ultrasound markers and maternal serum assessment. The high‑level stance is mixed: combined first‑trimester screening (nuchal translucency + maternal serum markers) is covered/medically necessary when counseling and patient preference requirements are met, whereas nuchal translucency (NT) measurement alone and fetal nasal bone assessment are not covered / considered not medically necessary for certain products due to insufficient evidence.

Key thresholds and coverage summary

Gestational age for NT measurement10 to 13 weeks of gestation

Gestational age for fetal nasal bone assessment11 to just before 14 weeks of gestation

High NT marker prompting additional testingNT ≥ 4.0 mm (may indicate high likelihood of Down syndrome; affects a very small percentage ~0.09%-0.3% of cases)

Scope summaryDefines medical necessity and coverage stance for first‑trimester Down syndrome screening that incorporates maternal serum markers and fetal ultrasound markers (nuchal translucency and fetal nasal bone) for pregnant individuals in the first trimester; specifies coverage differences for combined screening versus NT alone and nasal bone assessment, and lists applicable CPT codes.

Coverage stanceMixed: Combined first‑trimester screening (NT + maternal serum markers) considered medically necessary when counseling and patient desire are met; NT alone and fetal nasal bone assessment not covered / not medically necessary for Medicare Advantage and Commercial products due to insufficient evidence or variable accuracy.