DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for Obstetrical Ultrasound 

Definitions

Detailed Anatomic Ultrasound - a prenatal ultrasound performed between 18 and 22 weeks of pregnancythat checks on the physical development of the fetus and can detect certain congenital disorders as wellas major anatomical abnormalities. The healthcare provider will take measurements to ensure the fetus is growing appropriately for its age.

Highmark Health Options (HHO)- Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services WV Mountain Health Trust (MHT) and West Virginia Health Bridge (WVHB) including an expansion plan (WVHB ABP Alternative Benefit Plan) and WVCHIP members.

Pregnancy Trimesters -

• First trimester (first day of last menstrual period to 13 weeks and 6 days): The time when fertilization and major organ development occurs.

• Second trimester (14 weeks and 0 days to 27 weeks and 6 days): The time of rapid growth and development.

• Third trimester (28 weeks and 0 days to 40 weeks and 6 days): The time when the fetus’s weight increases and the organs mature so they will be ready to function after birth.

 

Standard Ultrasound - checks the fetus’s physical development, screens for major congenital anomalies, and estimates gestational age. A standard ultrasound exam also can provide information about the fetus’s position, movement, breathing, and heart rate; an estimate of the fetus’s size and weight; the amount of amniotic fluid in the uterus; the location of the placenta and the number of fetuses.

Transvaginal Ultrasound - A procedure used to examine the vagina, uterus, fallopian tubes, ovaries, and bladder. An instrument is inserted into the vagina that causes sound waves to bounce off organs inside the pelvis.

 

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

Procedures

Obstetrical ultrasounds can be performed in the OB/GYNs office or at a participating hospital without an authorization from the Plan

The following obstetrical ultrasounds are considered medically necessary under the following conditions:

ONE standard first trimester ultrasound is allowed per pregnancy when ANY of the following conditions exist (according to the American College of Radiology, 2018):

 

·       Confirmation of the presence of an intrauterine pregnancy; OR

·       Confirmation of fetal cardiac activity; OR

·       Estimation of gestational age; OR

·       Diagnosis or evaluation of multiple gestations, including determination of chronicity; OR

·       Evaluation of a suspected ectopic pregnancy; OR

·       Evaluation of the cause of vaginal bleeding; OR

·       Evaluation of pelvic pain; OR

·       Evaluation of suspected gestational trophoblastic disease; OR

·       Assessment of fetal anomalies, such as anencephaly; OR

·       Measurement of the nuchal translucency when part of a screening program for fetal

·       aneuploidy; OR

·       Imaging as an adjunct to chorionic villus sampling, embryo transfer, and localization and

·       removal of an intrauterine device; OR

·       Evaluation of maternal pelvic masses and/or uterine abnormalities

ONE standard second or third trimester ultrasound is allowed per pregnancy when ANY of the following conditions exist (according to the American College of Radiology, 2018):

·       Screening for fetal anomalies; OR

·       Evaluation of fetal anatomy; OR

·       Estimation of gestational age; OR

·       Evaluation of suspected multiple gestation; OR

·       Evaluation of cervical length; OR

·       Evaluation of fetal growth; OR

·       Evaluation of significant discrepancy between uterine size and clinical dates; OR

·       Determination of fetal presentation; OR

·       Evaluation of fetal well-being; OR

·       Suspected amniotic fluid abnormalities, OR

·       Evaluation of premature rupture of membranes and/or premature labor; OR

·       Evaluation of vaginal bleeding; OR

·       Evaluation of abdominal or pelvic pain; OR

·       Suspected placental abruption, OR

·       Suspected fetal death, OR

·       Follow-up evaluation of fetal anomaly; OR

·       Evaluation/follow-up of placental appearance and location, including suspected placenta previa, vasa previa, and abnormally adherent placenta; OR

·       Adjunct to amniocentesis or other procedures; OR

·       Adjunct to external cephalic version; OR

·       Evaluation of suspected gestational trophoblastic disease; OR

·       Evaluation of pelvic mass; OR

·       Suspected uterine anomalies.

ONE detailed anatomic ultrasound is allowed per pregnancy. This ultrasound must be billed with any one of the high-risk pregnancy diagnosis codes listed under the ‘Coding Requirements’ section below. This ultrasound may be performed for ANY of the following:

·       To evaluate for suspected anomalies based on history, abnormal lab results, or clinical evaluation, OR

·       When there are suspicious results from a limited or standard ultrasound, OR

·       There is a possibility of fetal growth restriction and multifetal gestation.

Transvaginal ultrasounds (TVU) (CPT code 76817) can be performed in the first trimester or later in the pregnancy to evaluate cervical length and/or the position of the placenta.

When obstetrical ultrasound services are not considered medically necessary:

·       Subsequent standard first, second, or third trimester ultrasounds, as a limited or follow-up ultrasound assessment is considered sufficient to provide re-examination of concerns.

·       Further anatomic ultrasounds because there is little to no clinical evidence of the need for multiple detailed fetal anatomic examinations

·       3D and 4D ultrasounds

·       Ultrasounds performed to solely determine the sex of the fetus or for keepsake photos of the fetus

·       Scans for growth evaluation performed less than two (2) weeks apart

·       Ultrasound to confirm pregnancy is the absence of other indications

A follow-up ultrasound in the first trimester in the absence of pain or bleeding

FDA

 

Ultrasound is the most widely used medical imaging method for viewing a fetus during a pregnancy. Ultrasounds provide parents with a great opportunity to view and hear the heartbeat of the fetus. In fetal ultrasound, three-dimensional (3-D) ultrasound allows visualization of some facial features and other body parts. Four-dimensional (4-D) is 3-D ultrasound in motion. While ultrasound is generally considered to be safe with very low risks, the risks may increase with unnecessary prolonged exposure to ultrasound energy, or when untrained users operate the device (FDA, 2024)

 

Post-payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by Highmark Health Options at any time pursuant to the terms of your provider agreement.

Place of Service:

Outpatient

REIMBURSEMENT

Participating facilities will be reimbursed per their Highmark Health Options contract.