Modifiedpartners_health_managementPolicy NC.CP.MP.129

Clinical Policy: Fetal Surgery in Utero for Prenatally Diagnosed Malformations

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Defines medical necessity criteria and coverage stance for in-utero fetal surgery interventions for specific prenatal malformations and identifies procedures considered not supported; applies to providers submitting claims to Partners Health Management (Carolina Complete Health adaptation).

Policy Summary

PayerPartners Health Management

PolicyClinical Policy: Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Policy CodePolicy NC.CP.MP.129

Change TypeMaterial criteria additions and revisions (FETO eligibility, SCT criteria, secondary review requirement, coding updates)

Effective Date

Last ReviewJul 1, 2026

Next Review Date

Key ActionObtain prior authorization/secondary review for repeat utero fetal surgery procedures and document that all specified coverage criteria are met.

SourceLink

POLICY UPDATE CHANGES

Added criteria for Fetal endoscopic tracheal occlusion (FETO) for left congenital diaphragmatic hernia (CDH) with specific severity and gestational-age criteria.

Under I.A. sacrococcygeal teratoma (SCT) criteria broadened to include minimally invasive correction or open fetal surgery and specified contraindications and gestational-age considerations for hydrops.

Added placement of thoraco-amniotic shunt for pleural effusion with or without secondary fetal hydrops to criteria set I.

All repeat utero fetal surgery procedures require secondary review.

Added selective fetal reduction by radio frequency ablation (RFA) or bipolar or microwave cord occlusion as an indication.

Quantified prior criterion I.G.5.a to include a fetal angle threshold of ≥ 30 degrees.

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Modifiedpartners_health_managementPolicy NC.CP.MP.129

Clinical Policy: Fetal Surgery in Utero for Prenatally Diagnosed Malformations

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Policy Summary

PayerPartners Health Management

PolicyClinical Policy: Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Policy CodePolicy NC.CP.MP.129

Change TypeMaterial criteria additions and revisions (FETO eligibility, SCT criteria, secondary review requirement, coding updates)

Effective Date

Last ReviewJul 1, 2026

Next Review Date

Key ActionObtain prior authorization/secondary review for repeat utero fetal surgery procedures and document that all specified coverage criteria are met.

SourceLink

POLICY UPDATE CHANGES

Added criteria for Fetal endoscopic tracheal occlusion (FETO) for left congenital diaphragmatic hernia (CDH) with specific severity and gestational-age criteria.

Added placement of thoraco-amniotic shunt for pleural effusion with or without secondary fetal hydrops to criteria set I.

All repeat utero fetal surgery procedures require secondary review.

Added selective fetal reduction by radio frequency ablation (RFA) or bipolar or microwave cord occlusion as an indication.

Quantified prior criterion I.G.5.a to include a fetal angle threshold of ≥ 30 degrees.

IPrimary criteria section

IISecondary review required

IIINot supported indications

07/2026Last revision

≥30%FETO o/e LHR threshold

Medical Necessity — Covered Indications and Criteria

Covered Indications (select conditions)

Covered when specific procedural and condition-specific criteria are met as detailed below.

I.A Sacrococcygeal teratoma (SCT): SCT with treatment including correction via a minimally invasive approach or via open fetal surgery; SCT resection is covered when ALL of the following are met:

I.A Sacrococcygeal teratoma (SCT) — detailed: (a) 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); (b) Does not have the following contraindications: (i) Type III or IV Altman-type tumors; (ii) severe placentomegaly; (iii) maternal cervical shortening.gestational age considerations noted

Contraindications are exclusionary for SCT resection.

I.B Lower urinary tract obstruction: Lower urinary tract obstruction without multiple fetal anomalies or chromosomal abnormalities: urinary decompression via vesico-amniotic shunting.

I.C CPAM and extralobar BPS: CPAM and extralobar bronchopulmonary sequestration with high-risk tumors: resection of malformed pulmonary tissue or placement of a thoraco-amniotic shunt when ALL of the following are met:

Includes drainage for macrocystic lesions and resection/ablation for solid masses.

I.C CPAM/BPS — detailed: (a) Hydropic fetus or at risk of developing hydrops; (b) Failure of one round of maternal antenatal corticosteroid, unless contraindicated.failure after one steroid course

Applies when conservative management has failed as specified.

I.D Pleural effusion with or without hydrops: Placement of a thoraco-amniotic shunt for pleural effusion with or without secondary fetal hydrops.

May include fetal pleural aspiration only when performed along with and prior to thoraco-amniotic shunt placement.

I.E Twin-twin transfusion syndrome (TTTS): Treatment depends on Quintero stage, maternal signs, gestational age and expertise and may include any of the following:

I.E Options: Amnioreduction; Fetoscopic laser ablation (with or without amnioreduction) when pregnancy is between 16 and 26 weeks gestation; Selective fetal reduction by radio frequency ablation (RFA) or bipolar or microwave cord occlusion.gestational age 16-26 weeks for fetoscopic laser ablation

Selective reduction methods added to allowed interventions.

I.F TRAP sequence: Ablation of anastomotic vessels of the acardiac twin (laser or radiofrequency ablation).

I.G Myelomeningocele repair: Open in utero repair when ALL of the following are met:

I.G Myelomeningocele repair — detailed: (1) Singleton pregnancy; (2) Upper boundary of lesion between T1 and S1; (3) Evidence of hindbrain herniation confirmed on fetal MRI; (4) Gestational age between 19 0/7 and 25 6/7 weeks; (5) None of the following contraindications: severe fetal kyphosis; risk of preterm birth (e.g., short cervix or previous preterm birth); placental abruption; previous hysterotomy in the active uterine segment.gestational age 19 0/7–25 6/7 weeks

I.H FETO for CDH: Fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia when ALL of the following are met:

I.H FETO for CDH — detailed: (1) Severe left-sided CDH; (2) Singleton pregnancy; (3) Severe pulmonary hypoplasia defined as observed-to-expected lung-to-head ratio (o/e LHR) ≥ 30%; (4) Gestational age ≤ 30 weeks.o/e LHR ≥ 30%; gestational age ≤ 30 weeks

FETO for right-sided CDH is typically investigational and may be reviewed case-by-case.

Not Medically Supported

III Not supported indications: In utero fetal surgery is not supported for the following indications: surgery for heart block, pulmonary valve, or aortic obstruction; tracheal atresia or stenosis; cleft lip and palate; in-utero stem cell transplantation; in-utero gene therapy; amnioexchange procedure for gastroschisis.

Procedures listed here are considered not supported by current evidence and may be denied.

Secondary Review Requirement

Additional administrative requirement

II Secondary review for repeat procedures: All repeat utero fetal surgery procedures require secondary review prior to approval.

Applies to health plans affiliated with Centene Corporation; providers should obtain prior authorization consistent with plan requirements and reference the policy when requesting review.

This policy addresses coverage for in‑utero fetal surgery, including both open and fetoscopic (endoscopic) approaches, for clearly specified prenatal malformations when the documented clinical criteria in Section I are met. Where Section I establishes procedure‑ and condition‑specific eligibility (for example, myelomeningocele repair or FETO for left congenital diaphragmatic hernia), those indications may be considered medically necessary if all listed criteria are satisfied. Per the policy updates, certain procedures and techniques have newly quantified thresholds (see Section I.H for FETO eligibility).

Open or endoscopic fetal surgery performed for indications enumerated in Section III (the list of procedures "not supported") is not covered under this policy. When a requested open or fetoscopic fetal surgical intervention falls within Section III, the procedure is considered unsupported by current evidence and is outside the scope of coverage; such requests should be denied or not authorized unless new evidence or an exceptions process is explicitly documented and approved.

Sacrococcygeal teratoma (SCT) management is included among covered indications when the specific I.A criteria are met. Coverage may include correction via a minimally invasive approach or open fetal surgery 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), provided the fetus does not have exclusionary contraindications.

Contraindications that preclude SCT resection under this policy include Altman Type III or IV tumors, severe placentomegaly, and maternal cervical shortening. When one or more of these contraindications is present, fetal SCT resection is not supported per the policy and should not be authorized. Clinical documentation must explicitly address presence or absence of these contraindications when authorization is requested.

Procedures listed under Section III are considered not supported by current evidence and therefore are not medically necessary under this policy. Examples specified in Section III include surgery for heart block, pulmonary valve or aortic obstruction; tracheal atresia or stenosis; cleft lip and palate; in‑utero stem cell transplantation; in‑utero gene therapy; and amnioexchange for gastroschisis.

Because these indications are described as not supported, requests for open or endoscopic fetal surgery for any of the Section III conditions should be processed as not medically necessary unless compelling new evidence and an approved exceptions pathway are documented.

This policy also specifies that procedures failing to meet the policy’s quantitative thresholds or explicit eligibility limits are outside the covered indications. For example, FETO for left congenital diaphragmatic hernia requires severe left‑sided CDH, an observed‑to‑expected lung‑to‑head ratio ≥ 30%, and gestational age ≤ 30 weeks; FETO requests that do not meet these numeric thresholds are not supported.

Similarly, other procedures described in Section I include explicit gestational‑age windows or prerequisite findings (for example, myelomeningocele repair gestational age limits and SCT hydrops occurring earlier than appropriate for delivery). If a proposed fetal procedure does not meet the specified numeric or timing criteria in Section I, it should be considered outside coverage and at risk for denial unless additional, policy‑specified exceptions apply.

Billing and Procedure Codes

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.
59074	Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance.

Referenced HCPCS CodesHCPCS

S2401	Repair, urinary tract obstruction in the fetus, procedure performed in utero.
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.

Covered CPT Codes (added)CPTCovered

CPT	CPT codes added to the policy (coding added 07/26).

Gestational age limits — quick reference key values for procedures

Myelomeningocele repairGestational age window 19 0/7 to 25 6/7 weeks

SCT with hydrops (example)High‑risk SCT with hydrops developing earlier than appropriate for delivery (example window cited: ~28–32 weeks)

FETO for CDHGestational age limit: ≤ 30 weeks

Observed-to-expected lung-to-head ratio (o/e LHR) — threshold for FETO

o/e LHR threshold for severe pulmonary hypoplasia (FETO eligibility)>= 30%

ContextSpecified as 'quotient of the observed-to-expected lung-to-head ratios' defining severe pulmonary hypoplasia for left CDH

Prior Authorization, Documentation, and Operational Steps

Prior Authorization

Secondary review required for repeat fetal surgery

All repeat utero fetal surgery procedures require secondary review prior to approval; obtain secondary review / prior authorization consistent with plan requirements before scheduling repeat fetal surgery.

Prior Authorization

Obtain prior authorization and cite procedure codes

Prior authorization is required for fetal surgical procedures; providers must obtain authorization demonstrating that the applicable coverage criteria are met and reference the CPT/HCPCS codes listed in the policy when requesting review.

Step Therapy

Sequence interventions for CPAM based on lesion type

For CPAM with hydropic fetuses (approximately 20–32 weeks), choose less invasive drainage procedures for macrocystic lesions or thoraco-amniotic shunting based on lesion type; solid masses should be managed with resection or ablation.

Clinical Background and Rationale

Maternal‑fetal surgery carries significant maternal and fetal risks and is associated with a high rate of preterm birth for the fetus. Because of these risks, the policy restricts coverage to a narrow set of indications with defined severity, laterality, gestational‑age windows, and contraindications, and requires that procedures be performed at centers with multidisciplinary fetal therapy capability. This risk profile and the frequent occurrence of prematurity in operated fetuses justify the policy’s strict eligibility criteria and the requirement for careful documentation and prior authorization when indicated.

Terminology and Procedure Definitions

Open fetal surgery — definition and brief description

DefinitionOpen fetal surgery: hysterotomy performed, fetus partially externalized to allow repair of the abnormality, then returned to the uterus until delivery.

Indication contextConsidered when fetal condition is life‑threatening and intervention is the only option for fetal survival.

Procedural noteRequires major maternal surgery and is typically performed at centers with multidisciplinary fetal therapy expertise.

Fetoscopic surgery — definition and brief description

DefinitionFetoscopic surgery: minimally invasive techniques using small fiberoptic telescopes and instruments to enter the uterus through small openings and correct congenital malformations without removing the fetus.

Clinical advantage

Policy Changes and Revision Log

09/2024criteria_revision

Added FETO as a covered indication for severe left-sided congenital diaphragmatic hernia with quantified pulmonary hypoplasia (observed-to-expected LHR ≥ 30%) and gestational age limit ≤ 30 weeks; SCT criteria updated with explicit contraindications (Altman type III/IV, severe placentomegaly, maternal cervical shortening) and allowance for minimally invasive or open fetal surgery.

07/25clarification

Clarifying language added to Criteria III and criteria text; annual review and updates to criteria language (including I.G.5.a) were recorded.

07/26

Policy Summary

PayerPartners Health Management

PolicyClinical Policy: Fetal Surgery in Utero for Prenatally Diagnosed Malformations

Policy CodePolicy NC.CP.MP.129

Change TypeMaterial criteria additions and revisions (FETO eligibility, SCT criteria, secondary review requirement, coding updates)

Effective Date

Last ReviewJul 1, 2026

Next Review Date

Key ActionObtain prior authorization/secondary review for repeat utero fetal surgery procedures and document that all specified coverage criteria are met.

SourceLink

On This Page

Associated requirementApplies with other FETO criteria including severe left-sided CDH and gestational age <= 30 weeks

Observed-to-expected lung-to-head ratio — reference key

o/e LHR numeric criterion>= 30%

PurposeUsed to define severe pulmonary hypoplasia for eligibility for fetal endoscopic tracheal occlusion (FETO)

Applied withSevere left-sided CDH and gestational age <= 30 weeks as joint criteria

Fetal angle threshold (I.G.5.a)

Fetal angle threshold (criterion I.G.5.a)>= 30 degrees

Nature of changePreviously qualitative criterion quantified to include a fetal angle threshold of ≥ 30 degrees

ContextPart of revisions clarifying myelomeningocele repair eligibility (I.G) per policy update

Gestational age limit for FETO

Numeric gestational age limit for FETO<= 30 weeks

Coupled criteriaMust be met along with severe left-sided CDH and o/e LHR >= 30%

Status noteFETO for right-sided CDH typically investigational and reviewed case-by-case

Drainage procedures for CPAM with dominant cysts
Thoraco-amniotic shunt or resection/ablation for solid masses

Step Therapy

Attempt conservative measures (one steroid course) before some interventions

Where specified in criteria (e.g., CPAM/BPS), attempt conservative management such as a trial of one round of maternal antenatal corticosteroid and document failure of that trial (unless contraindicated) before proceeding to certain fetal interventions.

Document one round of maternal antenatal corticosteroid and its failure when required
If contraindicated, note the contraindication in the record

Documentation Required

Refer to multidisciplinary fetal therapy center and document counseling

Refer candidates for fetal procedures (for example, myelomeningocele repair) to a fetal therapy center with multidisciplinary expertise and document that counseling about management options and referral occurred.

Document referral to a fetal therapy center
Document counseling about all management options and center consultation

Documentation Required

Required clinical documentation to support coverage criteria

Include clinical documentation demonstrating that all specified coverage criteria are met for the chosen fetal procedure (examples below); submit these materials with the authorization request.

Severity and laterality of congenital diaphragmatic hernia and observed-to-expected LHR
Gestational age and singleton status where required
Presence/absence of contraindications for SCT (Altman type, placentomegaly, cervical shortening)
Record of prior conservative therapy (e.g., antenatal corticosteroid) when required

Denial Risk

Procedures not supported (do not perform/seek coverage)

Do not perform or seek coverage for procedures listed as not supported by current evidence; these indications may be denied.

In-utero stem cell transplantation
In-utero gene therapy
Amnioexchange for gastroschisis
Surgery for heart block, pulmonary valve, or aortic obstruction
Tracheal atresia or stenosis
Cleft lip and palate

Denial Risk

Denial risk when procedures fall outside explicit criteria

Procedures that do not meet the policy’s explicit quantitative or other eligibility criteria (for example, FETO when observed-to-expected LHR is < 30% or gestational age exceeds 30 weeks, or when singleton requirement is not met) are at risk for denial.

FETO requires observed-to-expected LHR ≥ 30% and gestational age ≤ 30 weeks
Singleton pregnancy required where specified
SCT resection exclusion criteria (Altman type III/IV, severe placentomegaly, maternal cervical shortening) must be absent

Less traumatic than open surgery, reduces risk of preterm labor, and allows the fetus to remain in utero until more mature for delivery and neonatal care.

Use casesEmployed for indications where minimally invasive access can achieve the therapeutic goal (e.g., fetoscopic laser ablation for TTTS, certain shunt placements).

FETO — definition and intended physiologic effect

DefinitionFetal endoscopic tracheal occlusion (FETO): a fetoscopic procedure for severe left-sided congenital diaphragmatic hernia (CDH) that occludes the fetal trachea to promote lung growth.

Physiologic intentTracheal occlusion increases lung fluid retention and stimulates pulmonary growth to ameliorate pulmonary hypoplasia.

Eligibility in policyCovered when severe left-sided CDH, o/e LHR >= 30%, singleton pregnancy, and gestational age <= 30 weeks are met.

Selective fetal reduction by RFA — definition and added techniques

DefinitionSelective fetal reduction by radiofrequency ablation (RFA): procedure to occlude fetal cord vessels to selectively reduce one fetus in multiple gestation.

Additional permitted techniquesPolicy also includes bipolar or microwave cord occlusion as acceptable techniques for selective fetal reduction.

Policy contextAdded as an indicated fetal procedure under I.E.3 in the revised policy language.

coding_update_and_approval

CPT coding entries were added to the policy and prior authorization/approval language reaffirmed for fetal surgical procedures.

07/01/2026policy_review_dateLatest

Policy last reviewed (document metadata last_review date updated).