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Medical Policy: 04.01.03
Original Effective Date: October 1991
Reviewed: August 2011
Revised: November 2008
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:
The home uterine activity monitor (HUAM) is a detection device intended for use in women at high risk for preterm labor and preterm birth. The monitoring device consists of a data recorder, a data transmitter, and a guard-ring tocodynamometer worn as a belt around the abdomen. The patient is usually instructed to use the device daily for two 1-hour periods. After monitoring, the patient transmits the recordings by telephone modem to a base station. Base station nurses facilitate transmission and analysis of the monitor tracings and maintain daily telephone contact with the patient to assess signs and symptoms and provide advice and counseling.
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Prior Approval:
Not applicable
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Policy:
Home uterine monitoring through a monitoring device and/or daily nursing contact is considered not medically necessary.
There is a substantial evidence base on home uterine monitoring activity for reducing pre-term birth in high-risk pregnant women. The available evidence suggests that HUAM does not improve health outcomes, and HUAM is not recommended by national organizations such as the American College of Obstetricians and Gynecologists and the United States Preventive Services Task Force.
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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.
- CPT 99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring
- HCPCS S9001 Home uterine monitor with or without associated nursing services.
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Selected References:
- Ressel G. ACOG Issues Recommendations on Assessment of Risk factors for Preterm Birth. American Family Physician, Vol 65;No.3;Feb. 2002.
- Dyson DC, Danbe KH, Bamber JA, et al. Monitoring women at risk for preterm labor. New England Journal of Medicine. 1998; 338(1):15-9.
- Brown HL, Britton KA, Brizendine EJ, et al. A randomized comparison of home uterine activity monitoring in the outpatient management of women treated for preterm labor. American Journal of Obstetrics and Gynecology, 1999; 180(4):798-805.
- Colton T, Kayne HL, Zhang Y, et al. A meta-analysis of home uterine activity monitoring. American Journal of Obstetrics and Gynecology. 1995; 173(5): 499-505.
- Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. ACOG Committee opinion: Home Uterine Activity Monitoring, International Journal of Gynecology and Obstetrics. 1996;54(1):71-7
- Corwin MJ, Mou SM, Sunderji SG, et al. Multicenter randomized clinical trial of home uterine activity monitoring: pregnancy outcomes for all women randomized. American Journal of Obstetrics and Gynecology. 1996;175(5):1281-5.
- McPheeters M, Thorp JM, Gavin NI, et al. Home uterine activity monitoring in the care of preterm labor; a review of the evidence. Obstetrics and Gynecology. 2000 Apr 1;95(4 Suppl 1):S75-S76.
- Iams JD, Newman RB, Thom EA et al. Frequency of uterine contractions and the risk of spontaneous preterm delivery. N Engl J Med 2002; 346(4):250-5.
- Management of Preterm Labor. Summary, Evidence Report/Technology Assessment: Number 18. AHRO Publication No. 01-E020, October 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/epcsums/pretermsum.htm.
- Home Uterine Monitors Not Useful For Predicting Premature Birth. National Institute of Child Health and Human Development. National Institute of Health. January 23, 2002. http://www.nichd.nih.gov/new/releases/uterine.cfm.
- ECRI. Home Uterine Activity Monitoring in Women at Risk for Preterm Birth. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 May 15. 9 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
- ECRI Institute. Home Uterine Activity Monitoring in Women at Risk for Preterm Birth. Plymouth Meeting (PA): ECRI Institute; 2010 Jan 07. 9p. [ECRI hotline response]. Also available: http://www.ecri.org.
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Policy History:
Date Reason Action
August 2011 Annual review Policy renewed
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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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