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Medical Policy: 04.01.02
Original Effective Date: September 2000
Reviewed: September 2011
Revised: September 2011
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 surgery has grown along with new developments in prenatal diagnosis, especially prenatal ultrasound. Although most fetal malformations are best managed after birth, fetal surgery has advanced due to the promise of the earliest possible intervention producing the best results.
Fetal surgery usually involves opening the gravid uterus, surgically correcting a fetal abnormality, and returning the fetus to the uterus and restoring uterine closure. Because fetal surgery jeopardizes the pregnancy and may put the mother as well as the fetus at risk, it must be approached as a specialized technique requiring a multidisciplinary approach. Since these surgeries are highly specialized and complex, those performed at centers with the required expertise and experience in the specific treatment may afford the best chances of achieving positive outcomes.
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Prior Approval:
Not applicable
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Policy:
Vesico-amniotic shunting as a treatment of urinary tract obstruction may be considered medically necessary in fetuses under the following conditions:
- Evidence of hydronephrosis due to bilateral urinary tract obstruction; AND
- Progressive oligohydramnios; AND
- Adequate renal function; AND
- No other lethal abnormalities or chromosomal defects.
Open in utero resection of malformed pulmonary tissue or placement of a thoraco-amniotic shunt may be considered medically necessary under the following conditions:
- Congenital cystic adenomatoid malformation or bronchopulmonary sequestration is identified; AND
- The fetus is at 32 weeks’ gestation or less; AND
- There is evidence of fetal hydrops, placentomegaly, and/or the beginnings of severe pre-eclampsia (i.e., the maternal mirror syndrome) in the mother
In utero removal of sacrococcygeal teratoma may be considered medically necessary under the following conditions:
- The fetus is at 32 weeks’ gestation or less; AND
- There is evidence of fetal hydrops, placentomegaly, and/or the beginnings of severe pre-eclampsia (i.e., maternal mirror syndrome) in the mother
In utero repair of myelomeningocele may be considered medically necessary under the following conditions:
- The fetus is at less than 26 weeks’ gestation; AND
- Myelomeningocele is present with an upper boundary located between T1 and S1 with evidence of hindbrain herniation
In utero repair of myelomeningocele is considered investigational in the following situations:
- Fetal anomaly unrelated to myelomeningocele
- Severe kyphosis
- Risk of preterm birth (e.g., short cervix or previous preterm birth)
- Maternal body mass index of 35 or more
Other applications of fetal surgery are considered investigational, including but not limited to, temporary tracheal occlusion as a treatment of congenital diaphragmatic hernia or treatment of congenital heart defects.
Due to a number of factors, including the rarity of the conditions and the small number of centers specializing in fetal interventions, the evidence on fetal surgery remains limited. Fetal surgery for many congenital conditions, including diaphragmatic hernia and heart defects, has not been shown to improve health outcomes in comparison with postnatal treatment. The available evidence is insufficient to demonstrate that fetal tracheal occlusion and aortic valvuloplasty provides improved health outcomes. For these and other applications of fetal surgery that are currently considered investigational, additional studies are needed to identify appropriate candidates and to evaluate longer term outcomes compared with postnatal management.
For conditions leading to fetal hydrops (certain cases of congenital cystic adenomatoid malformation, bronchopulmonary sequestration, of sacrococcygeal teratoma), for which mortality approaches 100%, fetal surgery may be considered medically necessary. Vesico-amniotic shunting for bilateral urinary tract obstruction may also be considered medically necessary to minimize the effects of this condition on kidney and lung development. Additional studies for these surgeries are needed to better define the appropriate surgical candidates, the most effective timing of the interventions, and the long-term health outcomes in surviving children.
Data from the MOMS trial show that prenatal repair of myelomeningocele reduces the need for shunting in the first 12 months after delivery and improves a composite measure of mental and motor function, with adjustment for lesion level, at 30 months of age. Prenatal surgery also improves the degree of hindbrain herniation and the likelihood of being able to walk independently when compared with postnatal surgery. The long-term impact on function needs to be evaluated, and benefits must be balanced against risks to mother and child. Thus, fetal surgery may be considered medically necessary following informed decision making for cases of prenatal myelomeningocele that meet the MOM study.
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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 diagnostic codes.
- 59076 Fetal shunt placement, including ultrasound guidance
- 59897 Unlisted fetal invasive procedure, including ultrasound guidance
- S2400 Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero
- 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
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Selected References:
- Adzick NS, Crombleholme TM, Morgan MA, et al. A rapidly growing fetal teratoma. Lancet 1997; 349(9051):538.
- Chisholm Ca, Heider AL, Kuller JA, et al. Prenatal diagnosis and perinatal management of fetal sacrococcygeal teratoma. American Journal of Perinatology 1999; 16:47-50.
- Farmer DL. Fetal surgery: a brief review. Pediatric Radiology 1998; 28(6):409-13.
- Graf JL, Housely T, Albenese CT, et al. A surprising histological evolution of preterm sacrococcygeal teratoma. Journal of Pediatric Surgery 1998; 33:177-9.
- Harrison MR. Fetal surgery. American Journal of Obstetrics and Gynecology 1996; 174(4):1255-64.
- Holterman AZ, Filiatrault D. Lallier M, et al. The natural history of sacrococcygeal teratomas diagnosed through routine obstetric sonogram: a single institution experience. Journal of Pediatric Surgery 1998; 33:899-903.
- Milner R, Adzick NS. Perinatal management of fetal malformations amenable to surgical correction. Opinions in Obstetrics and Gynecology 1999; 11:177-83.
- Quinn TM, Adzick NS. Fetal surgery. Obstetrics and Gynecology Clinics of North America 1997; 24(1):143-57.
- Uchiyama M, Iwafuchi M, Naitoh M, et al. Sacrococcygeal teratoma: a series of 19 cases with long-term follow-up. Eur Jour Ped Surg 1999; 9:158-62.
- Westerburn B, Feldstein VA, Sandberg P, et al. Sonographic prognostic factors in fetuses with sacrococcygeal teratoma. Journal of Pediatric Surgery 2000 Feb; 35(2):322-5; discussion 325-6.
- Yang ey, Adzick NS. Fetoscopy. Sem Lap Surg 1998; 5(1): 31-9.
- Harrison MR, Keller RL Hawgood SB et al. A randomized trial of fetal endoscopic tracheal occlusion for severe fetal congenital diaphragmatic hernia. N Engl J Med 2003; 349(20):1916-24.
- Walsh WF, Chescheir NC, Gillam-Krakauer M et al. Maternal-Fetal Surgical Procedures. Technical Brief No. 5. (Prepared by the Vanderbilt Evidenc-based Practice Center under Contract No. 290-2007-10065.) AHRQ Publication No. 10(11)-EHC059-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2011.
- Adzick NS, Thom EA, Spong CY et al. A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med. 2011 Mar 17; 364(11):993-1004. Epub 2011 Feb 9.
- Danzer E, Gerdes M, Bebbington MW et al. Preschool neurodevelopmental outcome of children following myelomeningocele closure. An J Obstet Gynecol 2010; 202(5):450 e 1-9.
- Fayoux P, Hosana G, Devisme L et al. Neonatal tracheal changes following in utero fetoscopic balloon tracheal occlusion in severe congenital diaphragmatic hernia. J Pediatr Surg 2010 45(4):687-92.
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Policy History:
Date Reason Action
September 2011 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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