Ultrasound in Pregnancy (including 3D, 4D and 5D Ultrasound)
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Cigna coverage policy governing use of obstetric ultrasound (including 3D/4D/5D) for members under Cigna-administered health benefit plans; provides guidance for coverage determinations and billing. Applies to providers submitting claims to Cigna Companies.
Removed policy statements allowing ultrasounds solely to determine fetal gender or to provide photographic representation; annual review noted no clinical policy statement changes.
Coverage Criteria for Obstetrical Ultrasound
Routine 2D Obstetrical Ultrasound
Covered when ALL of the following are met
Refer to CPT 76815 for limited exam.
Specialized/Follow-up Obstetrical Ultrasound
Covered when ALL of the following are met
Refer to CPT 76816 for follow-up, transabdominal approach, per fetus.
3D/4D/5D Obstetrical Ultrasonography
Codes 76376 and 76377 are listed as not medically necessary.
Second and Third Trimester Ultrasound Examination
Covered when there is a documented medical indication such as:
List taken verbatim from policy.
Cervical Length Screening
Covered when ALL of the following are met:
Policy cites evidence that identification and treatment with vaginal progesterone can reduce preterm birth.
Three-dimensional (3D), four-dimensional (4D) and five-dimensional (5D) obstetrical ultrasonography are addressed specifically in this policy. Cigna considers rendering services reported with CPT codes 76376 and 76377 for obstetrical 3D/4D/5D imaging to be not medically necessary when used to report three-dimensional, four-dimensional, or five-dimensional obstetrical ultrasonography.
The U.S. Food and Drug Administration notes that ultrasound devices are prescription devices and discourages use of ultrasound solely for nonmedical purposes, such as obtaining fetal “keepsake” videos, and recommends prudent, medically indicated use by trained providers. Consistent with this guidance and recent policy updates, statements that previously allowed ultrasounds solely to determine fetal gender or to provide photographic representation of the fetus have been removed from this policy.
Use of CPT codes 76376 and 76377 to report 3D/4D/5D rendering for obstetrical ultrasound is considered not medically necessary. Claims submitted with these codes for obstetrical 3D/4D/5D rendering may be denied as not covered.
Routine ultrasound scanning for uncomplicated singleton pregnancies after 28 weeks of gestation is not supported by the evidence and therefore should not be offered, per the cited NICE guideline.
Coding and Code-Based Rules
| 76815 | Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses |
| 76816 | Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus |
| 76376 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation. |
| 76377 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation. |
Provider Actions, Documentation, and Billing
Coverage determination requirements
Coverage determinations must consider the terms of the applicable benefit plan document, any applicable laws/regulations, relevant collateral materials including this Coverage Policy, and the specific facts of the case; services must be submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy to be reimbursed.
Medical necessity for 2D and specialized ultrasound
Up to two routine two-dimensional (2D) standard or limited obstetrical ultrasound examinations (CPT 76815) and specialized follow-up obstetrical ultrasound (CPT 76816) are considered medically necessary when supported by clinical indications; document clinical justification when submitting these services.
Prior authorization
The policy does not specify any required prior authorization processes for obstetrical ultrasound in the cited sections; providers should follow any separate prior authorization rules in the member's benefit plan or payer-specific requirements.
Cervical length screening — document short cervix and linkage to therapy
If midtrimester transvaginal cervical length screening identifies a short cervix (defined as ≤ 25 mm), document the measurement and consider treatment with vaginal progesterone per the policy; ultrasound screening can be used to identify candidates for this therapy.
- Short cervix threshold: transvaginal cervical length ≤ 25 mm (midtrimester).
- Identification of a short cervix links to eligibility for vaginal progesterone to reduce preterm birth risk.
Coding requirement and billing/code mismatch risk
When billing, use the most appropriate CPT codes effective on the date of submission and ensure billed codes match covered services per this policy; claims for services billed with codes not covered under the policy will be denied.
- Use current, appropriate codes as of the submission effective date.
- Claims submitted without covered code(s) under the applicable Coverage Policy will be denied as not covered.
Required documentation for ultrasound type and indication
Document the clinical indication and the type of obstetrical ultrasound performed (limited/standard/ specialized) when submitting claims for CPT 76815 or 76816; indicate whether the exam was transabdominal or transvaginal and include findings that justify specialized follow-up when applicable.
Clinical indication and exam documentation
Perform and document obstetric ultrasound only when there is a valid medical indication and record the clinical reason and elements of the examination appropriate to the trimester per professional practice parameters.
- Document the clinical indication (e.g., dating, anatomy, bleeding, fetal growth concerns).
- Record exam elements appropriate to trimester (fetal number, cardiac activity, presentation, amniotic fluid, biometry, anatomic survey, etc.).
Billing/code mismatch — ensure billed codes match covered services
Claims for services that are not accompanied by covered procedure codes under this Coverage Policy will be denied as not covered; verify that the codes submitted (for example, 76815 or 76816) are appropriate for the service rendered and supported by documentation.
- Ensure CPT codes reported match the service (limited vs. follow-up) and clinical documentation.
- Avoid billing noncovered codes for obstetrical imaging to prevent denials.
Nonmedical-use — risk of denial for keepsake/photographic exams
Do not perform or bill ultrasound exams solely for nonmedical purposes (e.g., fetal keepsake videos); the FDA discourages nonmedical use and such services may be removed from coverage or denied.
- Ultrasound solely for nonmedical purposes is discouraged by the FDA.
- Policy removed prior allowances for exams solely to determine fetal gender or provide photographic representation.
Background and Scope
This Coverage Policy governs the use of obstetric ultrasound during pregnancy, including conventional two-dimensional (2D) examinations and higher-dimensional modalities such as 3D, 4D and 5D imaging. It explains which 2D obstetrical ultrasound exams are considered medically necessary (including up to two routine 2D studies and clinically indicated follow-up exams), specifies that 3D/4D/5D rendering reported with CPT codes 76376 and 76377 is considered not medically necessary, and aligns policy language with FDA guidance discouraging nonmedical “keepsake” ultrasound use. The policy is intended to guide coverage determinations and billing for providers submitting claims to Cigna Companies.
Definitions
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