ModifiedCentenePolicy CP MP.129

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Defines medical necessity criteria and coding implications for in‑utero fetal surgical procedures for selected fetal malformations and identifies indications considered not supported by current evidence; applies to Centene-affiliated health plans and providers requesting coverage for IU fetal surgery.

Policy Summary

PayerCentene

PolicyFetal Surgery in Utero for Prenatally Diagnosed Malformations

Policy CodePolicy CP MP.129

Change TypeMaterial revisions — added CPT 59072clarified MRI requirementupdated FETO thresholds

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit supporting clinical criteria and imaging, including fetal MRI confirmation of hindbrain herniation when applicable.

SourceLink

POLICY UPDATE CHANGES

Added CPT code 59072.

Updated criteria to require confirmation of hindbrain herniation on fetal MRI for myelomeningocele repair.

Updated FETO criteria for congenital diaphragmatic hernia to specify observed-to-expected lung-to-head ratio < 25% and gestational age < 30 weeks.

Removed previous maternal BMI contraindication and removed specific degree requirement for severe kyphosis in criteria.

multipleMedically necessary indications

>=1 repeatRepeat procedures

LHR<25%FETO severity threshold

19–25 wk

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Coverage and Medical Necessity Criteria

Medically necessary indications

Covered when ALL of the following indication-specific criteria are met for the listed procedures

Covered indications (any): IUFS is medically necessary for correction via minimally invasive approach for high-risk sacrococcygeal teratoma (SCT) with hydrops developing at a gestational age earlier than appropriate for delivery and neonatal care (e.g., ~28–32 weeks); SCT resection when meeting indication-specific criteria and without contraindications (including Type III/IV Altman tumors, severe placentomegaly, maternal cervical shortening); resection or thoraco-amniotic shunt for congenital pulmonary airway malformation (CPAM) or extralobar bronchopulmonary sequestration (BPS) with high-risk tumors; vesico-amniotic shunting for lower urinary tract obstruction without multiple fetal anomalies or chromosomal abnormalities; placement of a thoraco-amniotic shunt for pleural effusion with or without secondary fetal hydrops (or amnioreduction); fetoscopic laser ablation with or without amnioreduction for twin–twin transfusion syndrome (TTTS) when pregnancy is between 16 and 26 weeks gestation (selection dependent on Quintero stage, maternal signs/symptoms, gestational age, and available expertise); ablation of anastomotic vessels for twin‑reversed arterial perfusion (TRAP) sequence (eg, laser or radiofrequency ablation); myelomeningocele repair when ALL of the following are met: singleton pregnancy; upper boundary of lesion between T1 and S1; gestational age 19 0/7–25 6/7 weeks; evidence of hindbrain herniation confirmed on fetal MRI; and absence of specified contraindications (eg, severe kyphosis, risk of preterm birth such as short cervix or previous preterm birth, previous hysterotomy in the active uterine segment, placental abruption); fetal endoscopic tracheal occlusion (FETO) for severe left-sided congenital diaphragmatic hernia (CDH) when ALL of the following are met: severe pulmonary hypoplasia defined as observed‑to‑expected LHR < 25%; and gestational age < 30 weeks.

See policy document for full nested contraindications and procedure-specific details.

Not supported indications

The policy states current evidence does not support IUFS for the following

Not supported indications: Tracheal atresia or stenosis; surgery for heart block, pulmonary valve, or aortic obstruction; cleft lip and palate; in‑utero gene therapy; in‑utero stem cell transplantation; amnioexchange procedure for gastroschisis.

These indications are listed as not supported by current evidence.

Contraindications to open fetal surgery for sacrococcygeal teratoma (SCT) should be confirmed before proceeding. Type III or IV Altman‑type tumors, severe placentomegaly, maternal cervical shortening, and significant maternal medical issues are listed as exclusions for open fetal resection. These factors are used by fetal therapy centers to identify patients at increased maternal or fetal risk for which open in‑utero intervention is not appropriate.

Decisions about open fetal surgery for SCT must consider the timing of hydrops relative to fetal maturity; interventions are generally reserved for high‑risk SCT with hydrops developing at gestational ages too early for delivery (for example, ~28–32 weeks), and contraindications above would preclude open surgery.

Coverage determinations for in‑utero fetal surgery are made in the context of each member’s contract and applicable program rules. All coverage is subject to the terms, conditions, exclusions and limitations of the member’s evidence of coverage, certificate of coverage, policy or contract, and state or federal program requirements (for example, Medicaid or Medicare) take precedence where they conflict with this clinical policy.

The policy identifies several indications for which current evidence does not support open or endoscopic fetal surgery. Examples explicitly listed as not medically necessary include tracheal atresia or stenosis, in‑utero repair of cleft lip and palate, interventions for isolated cardiac conduction or valve obstructions (e.g., surgery for heart block, pulmonary valve, or aortic obstruction), in‑utero gene therapy, in‑utero stem cell transplantation, and procedures such as amnioexchange for gastroschisis. Requests for these procedures are considered unsupported by current evidence and are not covered under the medical necessity criteria in this policy.

Billing and Procedure Codes

Referenced CPT CodesCPT

59001	Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance).
59076	Unspecified in excerpt (referenced).
59897	Unlisted fetal invasive procedure, including ultrasound guidance, when performed.
59072	Fetal umbilical cord occlusion, including ultrasound guidance.

Referenced HCPCS/CPT S-codesHCPCS

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.
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.
S2411	Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome.

Observed-to-expected lung-to-head ratio (o/e LHR) — severity threshold for FETO

Threshold valueObserved-to-expected lung-to-head ratio (o/e LHR) < 25%

Associated conditionSevere left-sided congenital diaphragmatic hernia (CDH)

Gestational age constraintGestational age < 30 weeks for FETO

Policy tie-inFETO indicated when severe pulmonary hypoplasia is defined by o/e LHR <25%

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for all in‑utero fetal surgery procedures. This clinical policy is used to assist in making coverage decisions and administering benefits; providers should follow applicable Health Plan prior authorization procedures and submit requests before scheduling procedures.

All requests for in‑utero fetal surgery require prior authorization.
All repeat utero fetal surgery procedures require secondary review in addition to prior authorization.

Denial Risk

Denial Triggers

Requests that do not meet the medical necessity criteria for the indicated conditions or that lack required documentation are subject to denial. Common denial triggers include: procedures for indications listed as not supported by evidence, gestational age outside specified ranges for the indication, presence of specified contraindications, and absence of multidisciplinary evaluation or referral documentation.

Background and Scope

Maternal‑fetal surgery comprises both fetoscopic (minimally invasive) and open approaches. Fetoscopic techniques use fiberoptic instruments and small uterine access ports to treat fetal anomalies while leaving the fetus in utero, whereas open fetal surgery involves a hysterotomy with partial externalization of the fetus to perform repairs when the condition is life‑threatening and deemed necessary for fetal survival.

The choice of approach depends on the fetal condition, the severity of disease, and gestational age. These procedures carry significant maternal and fetal risks—including an increased likelihood of preterm birth—and should be performed only at specialized fetal therapy centers with multidisciplinary expertise.

Definitions

Fetoscopic surgery

DefinitionMinimally invasive fetal surgery using small fiberoptic telescopes and instruments through small uterine openings to correct congenital malformations while keeping the fetus in utero.

Approach benefitsLess traumatic than open surgery; may reduce preterm labor and allows the fetus to remain in utero until more mature.

Typical use casesUsed for select fetal anomalies amenable to percutaneous or fetoscopic access (see policy for specific indications).

Open fetal surgery

DefinitionProcedure involving a hysterotomy with partial externalization of the fetus to expose and repair the abnormality when the condition is life‑threatening and believed necessary for fetal survival.

Indication contextConsidered when the fetal condition is life threatening and intervention is felt to be the only option for fetal survival.