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Medical Policy: 04.01.08
Original Effective Date: December 2005
Reviewed: January 2012
Revised: January 2012
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Fetal nuchal translucency refers to the ultrasound detection of subcutaneous edema in the fetal neck, and is measured as the maximal thickness of the sonolucent zone between the inner aspect of the fetal skin and the outer aspect of the soft tissue overlying the cervical spine or the occipital bone.
Protocols for the use of maternal serums markers in conjunction with fetal nuchal translucency may vary. However, the large United States Biochemistry, Ultrasound, Nuchal translucency trial used a combination of free beta human chorionic gonadotropin and pregnancy-associated plasma protein A. Other protocols have additionally used serum measurements of alpha fetoprotein, unconjugated estriol, and inhibin A.
In January 2007, The American College of Obstetricians and Gynecologists (ACOG) published a practice guideline on Screening for Fetal Chromosomal Abnormalities. These recommendations include first-trimester screening with nuchal translucency and biochemical markers for Down syndrome and the availability of screening and invasive diagnostic testing for aneuploidy prior to the 20th week of gestation.
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Prior Approval:
Not applicable
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Policy:
Screening for detection of Down syndrome incorporating maternal serum markers and conventional two dimensional ultrasound measurement of fetal nuchal translucency may be considered medically necessary in the first-trimester of pregnancy for women who are adequately counseled and desire information on the risk of having a child with Down syndrome.
Screening for detection of Down syndrome or other chromosomal defects using conventional ultrasound measurement of nuchal translucency alone is considered investigational.
The use of 3-D ultrasound- and 4-D ultrasound, for detection of Down syndrome or other chromosomal defects by assessing fetal nuchal translucency is considered not medically necessary.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 76813 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation
- 76814 each additional gestation
- 84163 Pregnancy-associated plasma protein-A
- 84702 Gonadotropin, chorionic (hCG); quantitative
- 84704 Gonadotropin, chorionic (hCG); free beta chain
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Selected References:
- U.S. Preventive Services Taskforce. Guide to Clinical Preventive Services, 2nd ed. 1996. Screening for Down syndrome.
- Haddow JE, Palomaki GE, et al. Screening of maternal serum for fetal Down's syndrome in the first trimester. N Engl J Med 1998; 338(14):955-61.
- Wald NJ, Rodeck C, Hackshaw AK et al. First and second trimester antenatal screening for Down's syndrome: the results of the serum, urine and ultrasound screening study (SURUSS). J Med Screen 2003; 10(2):56-104.
- Wapner R, Thom E, Simpson JL, et al. First-trimester screening for trisomies 21 and 18. N Engl J Med 2003; 349(15):1405-13.
- AAOG Committee Opinion. First trimester screening for fetal aneuploidy. No. 296, July 2004.
- Platt LD, Greene N, et al. Sequential pathways of testing after first-trimester screening for trisomy 21. Obstet Gynecol 2004; 104(4):661-6.
- Bahado-Singh R, Driscoll D et al. “Practice Bulletin #77 Screening for Fetal Chromosomal Abnormalities” Obstet Gynecol 2007; 109:217-227.
- Evans MI, Krantz DA, Hallahan TW, Galen RS. Meta-analysis of first trimester Down syndrome screening studies: free beta-human chorionic gonadotropin significantly outperforms intact human chorionic gonadotropin in multimarker protocol. Am J Obstet Gynecol. 2007 Mar;196 (3): 198-205.
- Rozenberg P, Bussieres L, Chevret S, Bernard JP, Malagrida L, Cuckle H, Chabry C, Durand-Zaleski I, Bidat L, Lacroix I, Moulis M, Roger M, Jacquenot Mc, Bault JP, Boukobza P, Boccara P, Vialard F, Giudicelli Y, Ville Y. Screening for Down syndrome using first trimester combined screening followed by second-trimester ultrasound examination in an unselected population. Am J Obstet Gynecol. 2006 Nov;195 (5):1379-87. Epub 2006 May 24.
- American College of Obstetricians and Gynecologists. Screening for fetal chromosomal abnormalities. ACOG Practice Bulletin number 77. Obstet Gynecol 2007; 109(1):217-27.
- Institute for Clinical Systems Improvement (ICSI). Routine Prenatal Care, 14th ed. July 2010. Accessed 1/6/12. Available at http://www.icsi.org.
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Policy History:
Date Reason Action
January 2011 Annual review Policy renewed
January 2012 Annual review Policy revised
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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