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Medical Policy: 04.01.06
Original Effective Date: April 1999
Reviewed: December 2011
Revised: October 2004
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:
Ultrasound is the transmission of high-frequency sound waves through tissues of varying densities. Piezoelectric crystals within a transducer transmit the echoes produced by the sound waves at interfaces between tissues. Images created by the echoes of the sound waves are transmitted from the transducer to a CRT or television monitor.
A newer variation of ultrasound still in the investigational phase is known as 3-D ultrasound. This involves computer generated images obtained from sound waves sent at differing angles instead of straight up and down. These images have more detail than conventional 2-D ultrasound. When the 3-D image of the fetus is seen in real time allowing visualization of fetal movement, the technology is referred to as 4-D or dynamic ultrasound. These 3-D/4-D images have even been marketed in shopping malls to eager expectant parents by freestanding ultrasound vendors. The FDA considers such use of ultrasounds for keepsake video purposes to be an unauthorized use of a medical device and these vendors have largely been eliminated as a result of enforcement efforts. However, some clinicians continue to market them as a way to enhance prenatal bonding despite a lack of clinical evidence to support this claim.
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Prior Approval:
Not applicable
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Policy:
Conventional 2-D ultrasound in maternity care may be considered medically necessary when at least one of the following conditions have been met:
- Ultrasound in diagnosing abnormal pregnancy,e.g.;
- Suspected ectopic pregnancy
- Suspected hydatidiform mole
- Threatened or missed abortion
- Congenital malformation, fetal or maternal
- Polyhydramnios or oligohydramnios
- Placenta previa
- Abruptio placenta
- Vaginal bleeding
- Ultrasound for diagnosing other conditions affecting the fetus or delivery, e.g.;
- Suspected abnormal presentation
- Suspected multiple gestation
- Significant discrepancy between uterine size and dates
- Elevated maternal serum alpha-fetoprotein
- Suspected fetal death
- Suspected anatomical uterine abnormality
- Maternal risk factors such as family history of congenital anomalies, chronic systemic disease (e.g., hypertension, diabetes, sickle cell disease), or substance abuse
- Suspected fetal growth abnormality, either growth retardation or macrosomia
- Determination of gestation for uncertain dates is allowed once per pregnancy.
Ultrasound in maternity care is not a covered benefit under the following circumstances:
- Conventional 2-D ultrasound for routine use in pregnancy without clinical justification, such as determination of fetal gender or to provide a keepsake image of the fetus is not a covered benefit because it is considered not medically necessary.
- 3-D/4-D ultrasound is not a covered benefit under any circumstances because it is considered investigational. Although 3-D/4-D imaging may improve visualization of fetal anomalies, evidence does not demonstrate improved health outcomes and/or improved treatment decision-making based on this detailed imaging.
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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.
- Ultrasound done in conjunction with some other procedures is usually considered an integral part of the procedure and should be included in the global fee or charge. For some conditions, it may be necessary to perform amniocentesis and complete ultrasound on the same day and at the same time, or at a different time. In that situation, code for amniocentesis (59000), ultrasound guidance (76946) and echography (76805).
- Codes 76801, 76802, 76805, 76810 through 76817 as appropriate to report conventional ultrasound.
- 76376 and 76377 may be used for 3-D ultrasound
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Selected References:
- Bofill, JA, Sharp, GH. Obstetric Sonography; Who to Scan, When to Scan, and by Whom. Obstetrics and Gynecology Clinics of North America: September 1998; 25 (3);465-478.
- Skukpski, DW, Chervenak FA, McCullough, LB. Is Routine Ultrasound Screening For All Patients? Clinics in Perinatology, December 1994; 21 (4) :707-722.
- Routine Ultrasound in Low-Risk Pregnancy- American College of Obstetricians and Gynecologists- ACOG Practice Patterns, Number 5, August 1997.
- Scharf A, Ghazwiny MF, Steinborn A, Baier P, Sohn C. Evaluation of two-dimensional versus three-dimensional ultrasound in obstetric diagnostics: a prospective study. Fetal Diagn Ther. 2001 Nov-Dec;16(6):333-41.
- American Institute of Ultrasound in Medicine. AIUM Practice Guidelines for the Performance of Antepartum Obstetric Ultrasound Examination. Copyright AIUM; 2003.
- American Institute of Ultrasound in Medicine. Policy Statement on 3-D Ultrasound Technology. Approved October 18, 1999.
- Canadian Coordinating Office for health Technology Assessment (CCOHTA): Technology Assessment Committee. Prenatal Ultrasound as a Screening Test. Ottawa, Canada: October 2002.
- Institute for Clinical Systems Improvement (ICSI). Prenatal ultrasound as a screening test. ICSI Technology Assessment Report No. 16 Updated October 2002. Accessed 11/2006 Available at URL address:http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=607.
- Goncalves LF, Lee W, Espinoza J, Romero R. Three and 4-dimensional ultrasound in obstetric practice: does it help? J Ultrasound Med. 2005 Dec; abstract
- ICSI Health Care Guideline: Routine Prenatal Care, 14th ed. July 2010.
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Policy History:
Date Reason Action
December 2010 Annual review Policy renewed
December 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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