CurrentNeighborhood Health Plan of Rhode IslandPolicy Obstetrical Ultrasounds- # 045

Obstetrical Ultrasounds

Defines coverage and medical necessity criteria for obstetrical ultrasound imaging for Neighborhood Health Plan of Rhode Island lines of business (except Extended Family Planning). Governs reimbursement limits and indications requiring prior authorization when more than three ultrasounds are requested during a pregnancy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyObstetrical Ultrasounds

Policy CodePolicy Obstetrical Ultrasounds- # 045

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionRequest prior authorization and document the specific clinical indication when more than three obstetrical ultrasounds are needed during a pregnancy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3routine ultrasounds allowed per pregnancy

>3additional ultrasounds reimbursable only if abnormality or threat suspected

0coverage for fetal gender determination (routine)

Obstetrical Ultrasound Coverage Rules

General Coverage Determination

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Up to three (3) routine obstetrical ultrasounds are reimbursed per pregnancy
More than three (3) ultrasounds during pregnancy are approved only if ONE of the following clinical situations is present
- Indication from First-Trimester list (see First-Trimester criteria group)
- Indication from Second- and Third-Trimester list (see Second/Third-Trimester criteria group)
- Indication from Additional follow-up list (see Additional/Follow-up indications)

(See policy for requirement to document specific clinical indication when more than three ultrasounds are requested and for prior authorization procedures.)

Indications for First-Trimester Ultrasonography

Any of the following indications justify an ultrasound in the first trimester (and support authorization for >3 total ultrasounds if present):

ANY of the following

To confirm the presence of an intrauterine pregnancy
To evaluate a suspected ectopic pregnancy
To evaluate vaginal bleeding
To evaluate pelvic pain
To estimate gestational age
To diagnose or evaluate multiple gestations
To confirm fetal cardiac activity
As adjunct to chorionic villus sampling, embryo transfer, or localization and removal of an intrauterine device
To assess for certain fetal anomalies (e.g., anencephaly) in patients at high risk
To evaluate maternal pelvic or adnexal masses or uterine abnormalities
To screen for fetal aneuploidy
To evaluate suspected hydatidiform mole

(These indications are taken from the policy's First-Trimester Ultrasonography list.)

Indications for Second- and Third-Trimester Ultrasonography

Any of the following indications justify an ultrasound in the second or third trimester (and support authorization for >3 total ultrasounds if present):

ANY of the following

Estimation of gestational age
Evaluation of fetal growth
Evaluation of vaginal bleeding
Evaluation of cervical insufficiency
Evaluation of a pelvic mass
Evaluation of suspected fetal death
Evaluation of abdominal or pelvic pain
Determination of fetal presentation
Adjunct to cervical cerclage placement
Evaluation of suspected multiple gestation
Evaluation of fetal well-being
Adjunct to external cephalic version
Evaluation of suspected ectopic pregnancy
Examination of suspected hydatidiform mole
Adjunct to amniocentesis or other procedure
Significant discrepancy between uterine size and clinical dates
Evaluation of suspected uterine abnormality
Evaluation of suspected amniotic fluid abnormalities
Evaluation of suspected placental abruption

(These indications are taken from the policy's Second- and Third-Trimester Ultrasonography list.)

Additional / Follow-up Indications

Other listed indications that support additional ultrasound during pregnancy:

ANY of the following

Evaluation for premature rupture of membranes or premature labor
Evaluation for abnormal biochemical markers
Follow-up evaluation of a fetal anomaly
Follow-up evaluation of placental location for suspected placenta previa
Evaluation for those with a history of previous congenital anomaly
Evaluation of fetal condition in late registrants for prenatal care
To assess findings that may increase the risk of aneuploidy

(These indications are taken from the policy's Additional/Follow-up indications list.)

Exclusions / Not Covered

Ultrasounds not covered:

ANY of the following

Routine ultrasound to determine fetal gender in the absence of concern about a gender-related genetic disorder
Ultrasound performed solely to provide a 'picture' (keepsake) of the fetus

(These exclusions are specified in the policy's Exclusions section.)

What Providers Must Do

Prior Authorization

Prior authorization required for >3 ultrasounds

Request prior authorization when more than three obstetrical ultrasounds are needed during a pregnancy; approval requires documentation of one or more listed clinical indications that represent suspected abnormality or threat to fetus/delivery.

Documentation Required

Documentation of clinical indication

Providers must document the specific clinical indication from the policy lists (first‑trimester, second/third‑trimester, or additional/follow‑up indications) to support reimbursement for additional ultrasounds beyond the routine three.

Prior Authorization

Authorization forms and contact

Use Neighborhood's provider resources to access Prior Authorization forms; for assistance contact Clinical Administrative Support at 401-459-6060 or fax authorization forms to 401-459-6023.

Clinical Background

Obstetrical ultrasound is employed to assess key aspects of pregnancy including gestational age, fetal number, fetal viability and placental location, and it can assist in the diagnosis of many major fetal anomalies. The policy notes that gestational age is most accurately determined in the first half of pregnancy, making early ultrasound particularly important for dating and related clinical decisions. (See description and clinical uses.)

Neighborhood’s policy specifies that, based on current evidence, three‑dimensional (3D) ultrasound is not required over conventional two‑dimensional (2D) ultrasonography. Until clinical evidence demonstrates a clear advantage for 3D imaging, 2D ultrasound remains the standard modality for routine obstetrical imaging under this policy.

At-a-Glance Policy Metrics

Key Statistics for Obstetrical Ultrasound Coverage

routine ultrasounds allowed per pregnancy3 routine obstetrical ultrasounds reimbursed per pregnancy

additional ultrasounds reimbursable only if abnormality or threat suspected>3 only when a diagnosis or condition is suspected that represents an abnormality of pregnancy or represents a threat to the fetus or the delivery

coverage for fetal gender determination (routine)Not covered — routine ultrasound to determine fetal gender is excluded unless concern about a gender-related genetic disorder

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyObstetrical Ultrasounds

Policy CodePolicy Obstetrical Ultrasounds- # 045

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionRequest prior authorization and document the specific clinical indication when more than three obstetrical ultrasounds are needed during a pregnancy.

SourceLink

On This Page

OpenPayer

Obstetrical Ultrasounds

Obstetrical Ultrasound Coverage Rules

What Providers Must Do

Procedure / Coding References

Clinical Background

Defined Terms

Policy Dates

At-a-Glance Policy Metrics