Prenatal Obstetrical Ultrasound
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Policy governing medical necessity, site-of-service, preauthorization, and coding for prenatal obstetrical ultrasound services for Johns Hopkins Health Plans participating organizations.
An approval statement and table were added to the Approval section.
Coverage Criteria for Prenatal Obstetrical Ultrasound
General medical necessity for 2-D prenatal ultrasounds
Covered when ALL of the following are met:
Additional medical necessity indications (first trimester)
Covered for the following first trimester indications:
Additional medical necessity indications (second and third trimester)
Covered for the following second/third trimester indications:
3-D ultrasound coverage
Covered when ALL of the following are met:
Coverage stance (informational in excerpt)
Policy lists covered prenatal obstetrical ultrasound procedures and references clinical guidance; no explicit 'covered when ALL/ANY' criteria are included in these chunks.
The policy explicitly excludes certain prenatal ultrasound services that are considered not medically necessary when not supported by contract benefits. Specifically, four-dimensional (4-D) ultrasounds, prenatal ultrasounds performed solely to determine fetal gender for non‑medical reasons, and ultrasounds performed solely to provide keepsake images for parents are listed as exclusions and are not covered unless a member's contract specifically provides benefits for these services.
The excerpt provided for this policy does not enumerate additional exclusion conditions beyond those present in the Exclusions section and notes that there were no changes to policy criteria in the most recent revision. If there are other exclusionary conditions elsewhere in the full policy, they are not present in the provided excerpt.
Any services listed in the Exclusions section — including 4‑D ultrasounds, non‑medical fetal gender determination, and ultrasounds performed only to create keepsake images — are considered not medically necessary under this policy and are therefore not covered unless specifically allowed by the member contract.
The revision history states "No changes to policy criteria" for the 01/20/2026 update and indicates administrative additions to the Approval section only. The provided excerpt does not include an enumerated list of additional conditions considered not medically necessary beyond those already listed in Exclusions.
Coding and Procedure Codes
| 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. |
| 76801 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation. |
| 76802 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester, transabdominal approach; each additional gestation. |
| 76805 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after the first trimester, transabdominal approach, single or first gestation. |
| 76810 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after the first trimester, transabdominal approach; each additional gestation. |
| 76811 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach, single or first gestation. |
| 76812 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach, each additional gestation. |
| 76813 | Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach, single or first gestation. |
| 76814 | Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach, each additional gestation. |
| 76815 | Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., Fetal heartbeat, 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 (e.g., reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, reevaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus. |
| 76817 | Ultrasound, pregnant uterus, real time with image documentation, transvaginal. |
| 76818 | Fetal biophysical profile; with non-stress testing. |
| 76819 | Fetal biophysical profile; without non-stress testing. |
| 76820 | Doppler velocimetry, fetal; umbilical artery. |
| 76821 | Doppler velocimetry, fetal; middle cerebral artery. |
| 76825 | Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording. |
| 76826 | Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study. |
| 76827 | Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete. |
Provider Actions, Authorization, and Documentation
Preauthorization required for >3 2‑D ultrasounds (non‑high‑risk) and for all 3‑D ultrasounds
Preauthorization is required for greater than three (3) 2‑D prenatal obstetrical ultrasounds in the course of a non‑high‑risk pregnancy and for all 3‑D ultrasounds; preauthorization is not required for emergent or life‑threatening conditions or for >3 ultrasounds in high‑risk pregnancies (see Appendix A).
- Preauthorization submissions must include documentation to support medical necessity when required (see documentation block).
- High‑risk pregnancies listed in Appendix A are exempt from the >3 limit.
CPT coding list referenced in policy
The policy enumerates the CPT procedure codes that are addressed in this policy for prenatal obstetrical ultrasound; the document does not specify separate prior authorization requirements per individual CPT code in the excerpt provided.
Site‑of‑service authorization and documentation for regulated spaces (PPMCO/USFHP)
For PPMCO and USFHP, outpatient hospital (regulated space) requires documentation to justify the site of service; greater than three (3) 2‑D ultrasounds in non‑high‑risk members still require preauthorization regardless of site of service.
- Outpatient hospital (regulated space) requires preauthorization and documentation of medical necessity when: no in‑network free‑standing facility meets access standards, the ultrasound is performed by a network MFM specialist whose office is in an outpatient hospital, or the diagnosis/procedure appears on the Exception List (Appendix B).
- Free‑standing facilities (non‑regulated) are the appropriate place of service for most prenatal ultrasounds; >3 ultrasounds require preauthorization for non‑high‑risk members even in free‑standing facilities.
Step therapy not applicable
No step therapy requirements are specified in the provided sections of this policy.
Include supporting documentation with preauthorization requests
When preauthorization is required (e.g., >3 2‑D ultrasounds in non‑high‑risk pregnancies and all 3‑D ultrasounds), the preauthorization request must include documentation that supports the medical necessity of the service.
- Include clinical indication(s), relevant history, and any imaging reports or prior ultrasound findings that justify additional studies or 3‑D imaging.
Required CPT codes for prenatal obstetrical ultrasound documentation
The policy lists the CPT procedure codes to be used for prenatal obstetrical ultrasound documentation and billing; these codes should be reported per the procedures performed.
Denial risk if required preauthorization is not obtained
Failure to obtain required preauthorization for greater than three (3) 2‑D prenatal ultrasounds in a non‑high‑risk pregnancy may result in claim denial.
- Preauthorization is also required for all 3‑D ultrasounds; lack of authorization when required can trigger denial.
No changes to policy criteria (administrative update)
An administrative approval statement and table were added to the Approval section; no changes were made to the policy criteria.
- The revision history specifies 'No changes to policy criteria.'
Background and Clinical Context
Ultrasound is recommended for all pregnant patients, with the timing and frequency dependent on clinical indication. For routine, non‑high‑risk pregnancies, Johns Hopkins Health Plans considers provision of up to three (3) two‑dimensional (2‑D) prenatal obstetrical ultrasounds during the course of pregnancy medically necessary for indications such as dating/estimated gestational age, nuchal translucency measurement, and screening for fetal anomalies. Use of obstetrical ultrasound should follow standard clinical guidance and ALARA principles, and additional or more frequent imaging is guided by specific maternal–fetal indications.
Definitions and Place of Service
Revision History and Policy Changes
Approval statement and approval table were added to the Approval section; no changes were made to policy criteria.
Superseded the prior policy version effective 04/01/2025.
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