ModifiedFidelis CarePolicy CP .MP.129

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Medical necessity criteria and coding implications for in-utero fetal surgery for selected prenatally diagnosed malformations affecting pregnant members of Fidelis Care (Centene-affiliated health plans).

Policy Summary

PayerFidelis Care

PolicyFetal Surgery in Utero for Prenatally Diagnosed Malformations

Policy CodePolicy CP .MP.129

Change TypeMaterial clinical revisions and coding updates

Effective Date

Next Review Date

Key ActionObtain prior authorization for all in‑utero fetal surgery procedures and submit secondary review for repeat procedures.

SourceLink

POLICY UPDATE CHANGES

Added confirmation on fetal MRI for certain myelomeningocele criteria.

Updated criteria for fetal endoscopic tracheal occlusion (FETO) for CDH including severe pulmonary hypoplasia definition and gestational age <30 weeks.

Removed previous specific maternal BMI contraindication.

Added CPT code 59072.

Removed specific degree requirement for severe kyphosis in Criteria I.G.S.a.

4CPT codes referenced

7HCPCS S‑codes referenced

>=1Repeat surgeries require review

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Coverage Criteria for In‑Utero Fetal Surgery

inv-01: Initial covered indications

Covered when ALL of the following are met for specified indications

Covered indications: Sacrococcygeal teratoma (SCT) requiring intervention: correction via a minimally invasive approach, or SCT resection for fetuses with high-risk SCT and hydrops developing at a gestational age earlier than appropriate for delivery and neonatal care (e.g., ~28-32 weeks) when no contraindications are present (contraindications include Type III/IV Altman tumors, severe placentomegaly, maternal cervical shortening).

See individual indication subcriteria in policy

Covered indications: Congenital pulmonary airway malformation (CPAM) or extralobar bronchopulmonary sequestration (BPS) with high-risk tumors requiring resection or placement of a thoraco-amniotic shunt.

Covered indications: Lower urinary tract obstruction without multiple fetal anomalies or chromosomal abnormalities when urinary decompression via vesico-amniotic shunting is planned.

Covered indications: Placement of a thoraco-amniotic shunt for pleural effusion with or without secondary fetal hydrops (including consideration of amnioreduction as temporizing measure).

Covered indications: Twin–twin transfusion syndrome (TTTS) when management is appropriate for Quintero stage, maternal signs/symptoms, gestational age and available expertise: fetoscopic laser ablation (with or without amnioreduction) typically when pregnancy is between 16 and 26 weeks' gestation.16-26 weeks

Procedure selection depends on Quintero stage and center expertise

Covered indications: Twin-reversed arterial perfusion (TRAP) sequence: ablation of anastomotic vessels of the acardiac twin (e.g., laser or radiofrequency ablation).

Covered indications: Myelomeningocele repair when ALL of the following are met: singleton pregnancy; upper boundary of lesion between T1 and S1; evidence of hindbrain herniation confirmed on fetal MRI; gestational age between 19 0/7 and 25 6/7 weeks; absence of contraindications such as severe kyphosis, risk of preterm birth (eg, short cervix or prior preterm birth), previous hysterotomy in the active uterine segment, or placental abruption.19 0/7 - 25 6/7 weeks

Imaging confirmation (fetal MRI) required per policy

Covered indications: Fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia (CDH) when ALL of the following are met: severe left-sided CDH; severe pulmonary hypoplasia defined as observed-to-expected lung-to-head ratio (O/E LHR) < 25%; gestational age < 30 weeks.O/E LHR < 25%; gestational age < 30 weeks

See policy thresholds for pulmonary hypoplasia

inv-02: Repeat procedure review

Additional criteria/limits

Repeat procedures: All repeat utero fetal surgery procedures require secondary review.

Secondary review required prior to coverage

Current evidence does not support in utero fetal surgery for several specific indications. These unsupported indications include tracheal atresia or stenosis; surgical procedures for heart block, pulmonary valve, or aortic obstruction; cleft lip and palate; in‑utero gene therapy; in‑utero stem cell transplantation; and the amnioexchange procedure for gastroschisis.

Coverage under this clinical policy is subject to the specific terms, conditions, exclusions and limitations set forth in the member's coverage documents (for example, evidence of coverage, certificate of coverage, policy or contract). State and federal requirements and applicable Health Plan administrative policies and procedures also apply, and the Health Plan may change, amend, or withdraw this clinical policy at any time.

Procedures that are listed as not supported by current evidence (see exclusions above) are considered not medically necessary under this policy.

This clinical policy is a coverage guideline and does not constitute medical advice or dictate clinical management. Providers are expected to exercise their professional judgment and remain solely responsible for the medical advice, diagnosis and treatment of members.

Coding and Clinical Thresholds

Referenced CPT CodesCPT

59001	Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance)
59076	Fetal shunt placement including ultrasound guidance
59897	Unlisted fetal invasive procedure, including ultrasound guidance, when performed
59072	Fetal umbilical cord occlusion, including ultrasound guidance

Referenced HCPCS S-CodesHCPCS

S2401
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
S2411	Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome

inv-09: FETO pulmonary hypoplasia threshold

ThresholdObserved-to-expected lung-to-head ratio (O/E LHR) < 25%

Associated conditionSevere pulmonary hypoplasia for congenital diaphragmatic hernia (CDH)

Gestational age contextApplied when gestational age is < 30 weeks (see FETO criteria)

inv-10: Myelomeningocele gestational age window

Gestational age window19 0/7 weeks to 25 6/7 weeks

IndicationMyelomeningocele candidates for in‑utero repair per ACOG/SMFM criteria

Provider Requirements and Administrative Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for in‑utero fetal surgery procedures. This includes all listed CPT and HCPCS S‑codes and any open or fetoscopic fetal surgery. Repeat in‑utero fetal surgery procedures require secondary review.

Prior authorization required for initial and repeat procedures (repeat = secondary review)
Include referral documentation and indication for procedure when requesting authorization

Note

Prior Authorization Governed by Health Plan Procedures

Follow Health Plan administrative policies and the effective date determined by the Health Plan when submitting requests and providing care. Coverage decisions are subject to the terms, conditions, exclusions and limitations of the member’s coverage documents.

Adhere to plan-specific prior authorization processes and timelines
If state Medicaid or Medicare NCD/LCD conflicts exist, those take precedence

Background and Scope

Maternal‑fetal surgery is a major procedure that carries significant risks to both the pregnant person and the fetus. The decision to pursue intervention depends on condition severity, gestational age, and whether fetal surgery is the only viable option to improve fetal survival. Two main approaches are described: fetoscopic (minimally invasive) surgery, which uses fiberoptic telescopes and instruments entering the uterus through small openings, and open fetal surgery, which involves a hysterotomy with partial exteriorization of the fetus. Many fetuses undergoing these procedures are born preterm, and such interventions should be performed at specialized fetal therapy centers with multidisciplinary expertise.

Definitions

inv-20: Fetoscopic surgery — definition and brief description

DefinitionFetoscopic surgery: minimally invasive technique using small fiberoptic telescopes and instruments entering the uterus through small surgical openings to correct congenital malformations without major incisions

Typical useUsed to correct selected fetal anomalies (eg, TTTS laser ablation, selected shunt placements) when a less invasive approach is appropriate

Setting requirementShould be performed at facilities with multidisciplinary fetal therapy expertise and intensive care capabilities

inv-21: Open fetal surgery — definition and brief description

DefinitionOpen fetal surgery: a hysterotomy with partial exteriorization of the fetus to expose and correct the fetal abnormality, after which the fetus is returned to the uterus for continued development

Indication

Policy Revision History and Material Changes

2024-06revision

Added FETO (fetal endoscopic tracheal occlusion) criteria for congenital diaphragmatic hernia including definition of severe pulmonary hypoplasia (observed-to-expected lung-to-head ratio <25%) and gestational age <30 weeks.

2024-01revision

Updated Criteria I.G.6. to specify maternal body mass index ≥ 40 with supportive references and recorded approval in January 2024.

2023-07-23approval

Policy Summary

PayerFidelis Care

PolicyFetal Surgery in Utero for Prenatally Diagnosed Malformations

Policy CodePolicy CP .MP.129

Change TypeMaterial clinical revisions and coding updates

Effective Date

Next Review Date

Key ActionObtain prior authorization for all in‑utero fetal surgery procedures and submit secondary review for repeat procedures.

SourceLink

On This Page

Referral and imaging (including fetal MRI where required) expected for candidates

Note

Consider Minimally Invasive Temporizing Options First

Consider less invasive, temporizing procedures (e.g., amnioreduction, percutaneous drainage, shunting, fetoscopic approaches) prior to proceeding to open maternal‑fetal surgery when clinically appropriate.

Document why minimally invasive options are not appropriate if proceeding to open fetal surgery
Examples of temporizing measures: amnioreduction, fetal shunting, percutaneous drainage

Documentation Required

Referral and Imaging Documentation

Refer potential candidates to a fetal therapy center with multidisciplinary expertise. Provide complete imaging, including fetal MRI when indicated (e.g., confirmation of hindbrain herniation for myelomeningocele), and clinical documentation per ACOG/SMFM recommendations.

Include fetal MRI reports and relevant ultrasound findings with the referral
Document counseling about risks, alternatives, and delivery planning at a fetal center

Denial Risk

Not Supported Indications

Current evidence does not support in utero fetal surgery for listed unsupported indications. Do not submit authorization requests for these indications without clear, compelling evidence and prior discussion with the Health Plan.

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

Note

Conflicts with Medicaid/Medicare

Coverage determinations are subject to the member’s benefit terms, applicable state Medicaid rules, and Medicare NCDs/LCDs. Where conflicts exist, state Medicaid provisions and Medicare determinations take precedence.

Verify member eligibility and benefits prior to authorization
When applicable, follow state Medicaid manual and CMS NCD/LCD guidance

Note

Coverage Is Conditional on Plan Terms

Coverage is conditional on plan terms, limitations, and exclusions. This policy is a guide to medical necessity and does not guarantee payment. Providers must follow plan contractual terms and submit required documentation to support medical necessity.

Ensure complete clinical documentation accompanies authorization requests to avoid denial
Administrative and contractual terms govern payment and coverage

Considered when the fetal condition is life‑threatening and intervention is felt to be required for fetal survival (eg, selected myelomeningocele repairs)

ImplicationAssociated with significant maternal and fetal risks and frequent preterm birth; should be done at specialized centers

inv-22: Additional definition(s) / key terms

Repeat procedure reviewAll repeat utero fetal surgery procedures require secondary review prior to coverage

Not supported indicationsIn utero fetal surgery is not supported for tracheal atresia/stenosis, surgery for heart block or pulmonary/aortic obstruction, cleft lip/palate, in‑utero gene therapy, in‑utero stem cell transplantation, or amnioexchange for gastroschisis

Facility expectationProcedures should be performed at centers with multidisciplinary teams, expertise, and intensive care services

Included confirmation on fetal MRI in Criteria I.G.3., added clarifying language to I.G.4., added CPT code 59072, removed ICD-10 codes, and completed external specialist review with approval dated 07/23/2023.

2025-05annual_reviewLatest

Annual review with coding and descriptions reviewed; removed specific degree requirement for severe kyphosis and removed prior maternal BMI contraindication language; references updated and internal specialist review completed (Approval Date = 05/25).