CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Fetal Surgery (Coverage Criteria)

This policy governs coverage and coding for fetal surgical interventions for selected congenital anomalies and applies to Medicare Advantage Plans and Commercial Products of Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyFetal Surgery (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 2, 2025

Next Review DateJan 2, 2025

Key ActionVerify member benefits and obtain authorization per the member's contract before proceeding.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5+clinical conditions discussed

MOMSRCT evidence supporting myelomeningocele repair

Codes listedcodes listed

1disclaimer sections

Coverage Criteria for Fetal Surgery

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Indications considered medically necessary: Any one of the following conditions when meeting the described clinical circumstances:

Vesicoamniotic shunting for urinary tract obstruction: Bilateral urinary tract obstruction with oligohydramnios, adequate renal function reserve, and no other lethal or chromosomal abnormalities; percutaneous decompression (vesicoamniotic shunting or stent placement) to permit urine flow into the amniotic space and protect renal and pulmonary development is considered medically necessary.

Goals are to protect kidneys from increased collecting-system pressure and to assure adequate amniotic fluid for lung development; supported by cohort studies and limited randomized data (PLUTO).

Thoracoamniotic shunt or prenatal resection for large CCAM/BPS: Large congenital cystic adenomatoid malformations (CCAM) or bronchopulmonary sequestrations (BPS) that produce thoracic compression or fetal hydrops (mortality approaches 100%) where prenatal decompression with a thoracoamniotic shunt or in-utero resection is indicated.

Mortality is approximately 100% when lesions are associated with fetal hydrops.

In-utero removal of sacrococcygeal teratoma (SCT): Large or highly vascular sacrococcygeal teratoma associated with fetal hydrops and high in-utero mortality where prenatal resection is necessary to prevent death from high-output cardiac failure; prenatal removal is considered medically necessary in this subset.

SCT may approach 100% in-utero mortality when large/vascular and associated with hydrops.

In-utero repair of myelomeningocele: Prenatal repair of myelomeningocele may be considered medically necessary when the fetus is less than 26 weeks gestation, the lesion’s upper boundary is between T1 and S1, and there is evidence of hindbrain herniation; decision follows informed consent and MOMS trial eligibility considerations.gestational age <26 weeks; lesion upper boundary between T1 and S1

MOMS trial demonstrated reduced need for ventricular shunting and improved composite mental/motor outcomes at 30 months, and improved hindbrain herniation and independent ambulation rates; benefits must be balanced against maternal and fetal risks.

Not medically necessary or experimental indications

Procedures considered not covered or experimental because current evidence is insufficient to demonstrate improved health outcomes compared with postnatal management.

Not medically necessary interventions: Fetal tracheal occlusion for congenital diaphragmatic hernia (temporary tracheal occlusion, e.g., balloon occlusion) and fetal cardiac interventions (including fetal intervention for evolving hypoplastic left heart syndrome, in-utero aortic or pulmonary valvuloplasty, fetal balloon atrial septostomy, and other fetal cardiac procedures) are considered not medically necessary/not covered due to insufficient evidence.

Additional studies are needed to identify appropriate candidates and to evaluate long-term outcomes compared with postnatal management.

Fetal surgery is considered medically necessary for Medicare Advantage Plans and Commercial Products only for the procedures specifically listed in this policy when the documented clinical criteria are met. These covered procedures include vesicoamniotic shunting for urinary tract obstruction, open in‑utero resection of malformed pulmonary tissue or placement of a thoracoamniotic shunt, in‑utero removal of sacrococcygeal teratoma, and in‑utero repair of myelomeningocele under the stated gestational and anatomic criteria. All other fetal surgeries not enumerated here are not covered for Medicare Advantage Plans and are considered not medically necessary for Commercial Products because the evidence is insufficient to show improved net health outcomes.

Some fetal interventions remain experimental or lack sufficient evidence to demonstrate improved outcomes. In particular, temporary fetal tracheal occlusion for congenital diaphragmatic hernia (HCPCS code S2400) and various fetal cardiac interventions (including procedures aimed at evolving hypoplastic left heart syndrome, critical pulmonary stenosis, or pulmonary atresia) have insufficient evidence and are considered not medically necessary / not covered per this policy. Additional studies are needed to define appropriate candidates and long‑term benefits compared with postnatal care.

Coding and Billing

Medically necessary codesCPT | HCPCS | mixedCovered

59076	Fetal shunt placement, including ultrasound guidance.
S2401	Repair, urinary tract obstruction in the fetus, procedure performed in utero.
S2402	Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero.
S2403	Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero.
S2404	Repair, myelomeningocele in the fetus, procedure performed in utero.
S2405	Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero.
S2409	Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified.

Not covered / not medically necessary codesHCPCSNot Covered

S2400

Repair, congenitally diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero.

Unlisted procedures processCPT

59897

Unlisted fetal invasive procedure including ultrasound guidance.

Provider Actions, Prior Authorization, and Billing Notices

Prior Authorization

Prior Authorization and Coding Note

Prior authorization: Not applicable. However, providers must verify member benefits and any authorization requirements for the listed fetal surgery codes prior to scheduling.

Verify benefits and authorization requirements with the member's plan before providing services.
Although the policy lists "Not applicable" for prior authorization, benefit documents and product-specific rules may impose prior authorization for some codes.

Note

Verify Benefits / Authorization

Benefits and payment are governed by the member’s subscriber agreement, Evidence of Coverage, or employer contract. BCBSRI may review and revise this policy; providers should check member-specific eligibility and benefits before performing services.

Coverage and payment are determined by the member's Benefit Booklet / Evidence of Coverage / Subscriber Agreement.
For member-specific benefit or coverage questions, contact the provider call center.

Denial Risk

Denial / Member Billing Risk

Providers must verify benefits and obtain any required pre-service approvals per the member’s contract. If services are determined to be not medically necessary or are non-covered under the member’s product, the provider may be liable for charges unless the member signs written agreement to accept financial responsibility in advance.

Services not medically necessary or non-covered may result in provider and/or member financial liability.
Refer to participation agreements and the member’s subscriber documents for billing and member notification requirements.

Note

Benefit Verification

Refer to the member’s Benefit Booklet / Evidence of Coverage / Subscriber Agreement for product-specific coverage of fetal surgeries; benefits vary by group and contract. Check eligibility and coverage limitations before scheduling procedures.

Benefits vary between groups and contracts — verify applicable surgery coverage and exclusions.
Non-covered or not medically necessary surgeries may not be payable under certain contracts.

Background on Fetal Surgery

Fetal surgery comprises prenatal operative interventions for select congenital anomalies that threaten postnatal survival or organ development. Techniques range from open hysterotomy‑based procedures (open fetal surgery) to less invasive fetoscopic or percutaneous approaches such as shunt placement. The general goals are to prevent progressive organ injury (for example, maintain lung or renal development), decompress obstructed systems, remove life‑threatening masses, or improve neurologic outcome for specific defects. Indications are condition‑specific and may include decompression of bilateral urinary tract obstruction, drainage or resection of large thoracic lesions causing hydrops, removal of highly vascular sacrococcygeal teratomas, and prenatal repair of myelomeningocele under strict gestational and anatomic criteria.

Definitions

Fetal surgery definition

DefinitionPrenatal surgical intervention performed by opening the gravid uterus (via hysterotomy/Cesarean incision) or using fetoscopic ports to correct a congenital abnormality and return the fetus to the uterus with uterine closure.

Approach typesOpen hysterotomy-based fetal surgery and minimally invasive fetoscopic procedures are included.

PurposeIntended to treat selected congenital anomalies associated with poor postnatal prognosis by preventing ongoing organ damage or improving outcomes prior to birth.

ScopeApplies to procedures performed in utero for conditions such as urinary tract obstruction, CDH, CCAM/BPS, sacrococcygeal teratoma, myelomeningocele, and select cardiac malformations.

Myelomeningocele

DefinitionA neural tube defect in which the spinal cord forms abnormally and is left open, exposing the meninges and neural elements to the intrauterine environment.

Clinical consequencesCan cause varying degrees of neurologic impairment to the legs and bowel/bladder, hindbrain herniation, cognitive impairment, and disorders of CSF circulation such as hydrocephalus requiring ventriculoperitoneal shunting.

Traditional managementPostnatal surgical repair after term delivery primarily to prevent infection and further neurologic dysfunction.

Rationale for fetal repairPrenatal surgical repair is proposed to cover the exposed spinal canal to prevent deleterious intrauterine exposure with the goal of improving neurologic outcomes and reducing associated complications.