CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Obstetrical Ultrasound Coverage (Coverage Criteria)

Defines Neighborhood Health Plan of Rhode Island coverage, limits, and medical necessity criteria for obstetrical ultrasound services for pregnancy across specified lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyObstetrical Ultrasound Coverage (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateDec 4, 2019

Key ActionObtain prior authorization when more than three obstetrical ultrasounds are needed by submitting the Medical Management Request form and contacting Clinical Administrative Support.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 3routine ultrasounds reimbursed per pregnancy

>3additional ultrasounds require one qualifying clinical situation

3+policy lists indications permitting >3

EFPlines of business excluded from coverage

2019last review dates up to

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Coverage Criteria for Obstetrical Ultrasound

inv-01: Routine and medically necessary additional ultrasounds

Covered when ALL of the following are met

Routine allowance: Neighborhood will reimburse for up to three (3) routine ultrasounds each pregnancy.<=3 ultrasounds

See list of indications for additional exams

ref.

This policy explicitly limits coverage for obstetrical ultrasound services and is not intended for non‑clinical purposes. Ultrasound exams performed solely to obtain a "picture" of the fetus are not a covered purpose and may be denied.

Routine ultrasounds performed only to determine fetal gender in the absence of a medical concern (for example, concern about a related genetic disorder) are not covered. Such gender‑determination scans without clinical indication are explicitly excluded from reimbursement.

Coding Reference

Coding referencemixed

affected codes

See Authorization Quick Reference Guide for coding details

Provider Actions, Authorization & Billing

Prior Authorization

Prior Authorization Required

Prior authorization is required when more than three (3) routine obstetrical ultrasounds are requested during a single pregnancy. Neighborhood will reimburse up to three routine ultrasounds; additional exams beyond three will be reimbursed only when one of the listed clinical indications (see Criteria) applies and an authorization is obtained.

Prior authorization required for >3 routine obstetrical ultrasounds
Reimburse up to three (3) routine ultrasounds per pregnancy; additional exams need authorization

Note

Authorization Contact & Form Submission

Providers should submit prior authorization requests using Neighborhood Health Plan of Rhode Island’s Medical Management Request Forms. For assistance with authorization submission or questions, contact Clinical Administrative Support.

Access forms on Neighborhood’s website: Providers > Resources & FAQs > Medical Management Request Forms

Definitions and Uses of Obstetrical Ultrasound

Obstetrical ultrasound — defined uses

Primary clinical usesDetermine gestational age, fetal number, and fetal viability

Anomaly and fetal assessmentDiagnose many major fetal anomalies and assess suspected fetal abnormalities

Placental and pregnancy-related assessmentsEvaluate placental location and other pregnancy-related conditions that may threaten the fetus or delivery

Safety and modality noteUltrasonography is safe for the fetus when used appropriately; 3D ultrasound is not required over conventional 2D per this policy

Clinical necessityObstetrical ultrasound may be necessary for many pregnancy conditions and is reimbursed when it addresses suspected abnormalities or threats to the fetus/delivery

Background

Ultrasonography is a clinically valuable tool in pregnancy for determining gestational age, fetal number, viability, major fetal anomalies, and placental location. The policy reflects the clinical utility of ultrasound while setting utilization limits: Neighborhood will reimburse up to three (3) routine ultrasounds per pregnancy, with approvals for additional exams allowed only when specific clinical indications are present. Three‑dimensional ultrasound is not required over conventional two‑dimensional techniques per the policy, and non‑clinical uses such as fetal pictures or routine gender determination are excluded.