Medical Policy: 04.01.06 

Original Effective Date: April 1999 

Reviewed: June 2018 

Revised: June 2018 


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.



Fetal ultrasound is a test performed during pregnancy, either to assess the gestational age or to evaluate fetal size, position, heartbeat, congenital malformations, suspected multiple fetuses or placental abnormalities. Two dimensional ultrasound is most commonly used. Three dimensional (3-D) and four dimensional (4-D) ultrasound create computer generated images viewed on video monitor that provide more detail and can produce more life-like images of the fetus. Five dimensional (5-D) ultrasound has been proposed as a means to automate the process of navigating the data obtained in a 3-D ultrasound to reduce dependency on ultrasound operator skill and experience and to increase reproducibility. This policy addresses the use of 3-D, 4-D, and 5-D fetal ultrasound in maternity care.


Although 3-D fetal ultrasound can produce more “realistic” and recognizable images than conventional 2-D ultrasound, the clinical significance of this remains unclear. The perceived superiority of 3-D ultrasound for a number of fetal abnormalities has not been established, and 2-D imaging remains the principal diagnostic modality.


Three dimensional (3-D) or volume ultrasonography acquires a volume (rather than a slice) of ultrasonographic data allowing one to see width, height and depth of images which is then stored. The stored data can be reformatted and analyzed in numerous ways. For example, surface rendering involves projecting the surface of a structure onto the screen, which allows curved structures, such as the fetal face, to be viewed in a single image that appears photographic in nature.


Suggested advantages of 3-D ultrasound compared to 2-D ultrasound in obstetrics include the following:

  • Three-dimensional ultrasound appears to be less operator dependent and provides a superior display of structures with complex anatomy compared to conventional ultrasonography.
  • Orientations and planes are not available with two-dimensional ultrasound, because of anatomic constraints for fetal position are available with three-dimensional ultrasound.
  • Volume data may be reviewed by millimeter after acquisition, simulating real-time scanning.
  • Archived volume data with suspected fetal anomalies may be reviewed with other physicians after completion of the ultrasound and data may be transmitted via the internet to other locations.
  • Three-dimensional ultrasound has improved accuracy of volume measurements to measure regular and irregular objects.
  • Volume rendered images are easily recognizable by both parents and physicians, which may facilitate decisions by families regarding continuing or terminating the pregnancy and are also said to enable parents to bond more effectively with the fetus. It may also assist them with the making lifestyle changes, such as stopping smoking or excessive alcohol intake.


Limitations of 3-D ultrasound of the fetus are as follows:

  • Suboptimal volume rendered images are obtained if there are inadequate amniotic fluids surrounding the structure of interest. This is a major limitation with oligohydramnios and as the fetus progresses towards term. The adjacent structures cannot be excluded from the rendered volume in these cases and this interferes with surface rendering.
  • Unacceptable surface rendering occurs with unfavorable fetal position and with adjacent or superimposed structures (e.g. limbs).
  • Image processing of the volume data may take additional time on the part of the examiner.
  • Real-time capacity is not generally available with three-dimensional ultrasound.


Four dimensional (4-D) ultrasonography refers to real-time visualization of 3-D images. The time vector (the fourth dimension) makes it possible to perceive a rapid update of the successive individual images displayed on the monitor at very short intervals which creates the impression of real-time. Fetal movements can be seen, providing a "live action" view. 4-D ultrasonography is also known as dynamic 3-D sonography.


Five dimensional (5-D) ultrasonography builds upon 3-D sonography, automating the process of acquiring diagnostic images based upon volume data through the use of a software package. The ultrasound system WS80A (Samsung Medison Co, Ltd, Seoul, Korea) includes several software packages focusing on specific areas including fetal brain and heart structure, nuchal translucency and fetal biometry.


The 5-D technology includes the following:

  • 5-D Heart Color: This automatically displays nine standard fetal echocardiography views with blood flow dynamics simultaneously in a single template. The intuitive workflow can simplify examination of the fetal heart and reduce operator dependency.
  • 5-D CNS+: This provides nine planes (axial, coronal, sagittal planes) of the fetal brain with anatomical landmarks and biometric measurements. The 5-D CNS+ combines clinical knowledge based cues with pattern classification algorithms to determine the best standardization planes that are clinically significant. It complies with the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guideline for the fetal brain.
  • 5-D Limb Vol: This technology provides an efficient way to rapidly measure fractional limb volume. This soft tissue parameter can be added to conventional 2-D ultrasound measurements of the fetal head (BPD) and abdomen (AC) to improve the precision of estimated fetal weight (EFW) and nutritional status. This computer assisted technology has clinical potential to detect and monitor malnourished fetuses with growth abnormalities.
  • 5-D NT: Offers nuchal translucency measurement solutions for first trimester fetal nuchal translucency measurements.
  • 5-D LB: Offers intuitive detection and measurement of fetal long bones.


5-D technology in fetal assessment in clinical practice:

  • Biometrics to measure biparietal diameter and crown-rump length and determine gestational age.
  • Nuchal translucency - manual measurement, semi-automatic; 5-D recognizes the correct mid-sagittal plane and provides improved Herman score.
  • Morphological assessment – 3-D and 4-D enhancements offer more capabilities for accurate assessment to aid diagnosis of visible anomalies, invisible anomalies and anomalies requiring analysis: cardiac, face and limbs, spina bifida.
  • Diagnosis of chorionicity and aminiocity in twin pregnancies.
  • Fetal risk assessment – characterizes risk that include aneuploidies, congenital heart defects, and spina bifida.



Although three dimensional (3-D), four dimensional (4-D) and five dimensional (5-D) ultrasound may provide improved imaging for certain areas of the fetal anatomy and abnormalities, it has not been demonstrated in clinical studies to alter management over standard two-dimensional (2-D) ultrasounds such that clinical outcomes are improved. Additional studies are needed to support this technology as a replacement for standard 2-D ultrasound. The evidence is insufficient to determine the effects of this technology on net health outcomes.


Practice Guidelines and Position Statements

The American College of Obstetricians and Gynecologists (ACOG)

2009 ACOG guideline on Ultrasonography in Pregnancy including the following: The technical advantages of three-dimensional ultrasonography include its ability to acquire and manipulate an infinite number of planes and to display ultrasound planes traditionally inaccessible by 2-dimensional ultrasonography. Despite these technical advantages, proof of a clinical advantage of three-dimensional ultrasonography in prenatal diagnosis in general is still lacking. Potential areas of promise include fetal facial anomalies, neural tube defects, and skeletal malformations where three-dimensional ultrasonography may be helpful in diagnosis as an adjunct to, but not a replacement for, two-dimensional ultrasonography. Until clinical evidence shows a clear advantage to conventional two-dimensional ultrasonography, three-dimensional ultrasonography is not considered a required modality at this time.


2012 ACOG reaffirmed their committee opinion regarding “Non-Medical use of Obstetric Ultrasonography”: ACOG has endorsed the following statement from the American Institute of Ultrasound in Medicine (AIUM) discouraging the use of obstetric ultrasonography for non-medical purposes (e.g., solely to create keepsake photographs or videos):


The AIUM advocates the responsible use of diagnostic ultrasound. The AIUM strongly discourages the non-medical use of ultrasound for psychosocial or entertainment purposes. The use of either two dimensional (2-D) or three dimensional (3-D) ultrasound to only view the fetus, obtain a picture of the fetus or determine the fetal gender without a medical indication is inappropriate and contrary to responsible medical practice. Although there are no confirmed biological effects on patients caused by exposures from present diagnostic ultrasound instruments, the possibility exists that such biological effects may be identified in the future. Thus ultrasound should be used in a prudent manner to provide medical benefit to the patient.


In summary, although 3-D and 4-D ultrasound may provide improved imaging for certain areas of fetal anatomy and abnormalities, it has not been demonstrated in clinical studies to result in improved health outcomes when compared to conventional 2-D ultrasound amaging.


In 2016, the American Academy of Obstetricians and Gynecologists (ACOG), issued practice bulletin No. 175 ultrasound in pregnancy, which states the following regarding three-dimensional ultrasonography: “Three-dimensional ultrasonography represents an advance in imaging technology. With three-dimensional ultrasonography, the volume of a target anatomic region can be calculated. The defined volume then can be displayed in three orthogonal two-dimensional planes representing the sagittal, transverse, and coronal planes of a reference two-dimensional image within the volume. The volume also can be displayed in its rendered format, which depicts the topographic anatomy of the volume. The technical advantages of three-dimensional ultrasonography include its ability to acquire and manipulate a large number of planes and to display ultrasound planes traditionally inaccessible by two-dimensional ultrasonography. Despite these technical advantages, proof of a clinical advantage of three-dimensional ultrasonography in prenatal diagnosis in general still is lacking. Potential areas of promise include fetal facial anomalies, neural tube defects, fetal tumors, and skeletal malformations for which three-dimensional ultrasonography may be helpful in diagnosis as an adjunct to but not a replacement for two-dimensional ultrasonography.”


American College of Radiology (ACR)-American College of Obstetricians and Gynecologists (ACOG)-American Institute of Ultrasound in Medicine (AIUM)- Society of Radiologist in Ultrasound (SRU)

In 2013, ACR-ACOG-AIUM-SRU issued a practice parameter for the performance of obstetrical ultrasound, this guideline does not mention or indicate the use of 3D or 4D ultrasound.

Equipment specifications: These studies should be conducted with real-time scanners, using a transabdominal and/or transvaginal approach. A transducer of appropriate frequency should be used. Real time sonography is necessary to confirm the presence of fetal life through observation of cardiac activity and active movement.


Classification of Fetal Sonographic Examinations

First Trimester Ultrasound Examination: A standard obstetrical sonogram in the first trimester includes evaluation of the presence, size, location, and number of gestational sac(s). The gestational sac is examined for the presence of the yolk sac and embryo/fetus. When and embryo/fetus is detected, it should be measured and cardiac activity recorded by 2D video clip or M-Mode. Use of spectral Doppler is discouraged. The uterus, cervix, adnexa and cul de sac region should be examined.


Standard Second or Third Trimester Examination: A standard obstetrical sonogram in the second or third trimester includes an evaluation of fetal presentation, amniotic fluid volume, cardiac activity, placental position, fetal biometry, and fetal number, plus an anatomic survey. The maternal cervix and adnexa should be examined as clinically appropriate when technically feasible.


Limited Examination: A limited examination is performed when a specific question requires investigation. For example, in most routine nonemergency cases a limited examination could be performed to confirm fetal heart activity in a bleeding patient, or to verify a fetal presentation in laboring patient. In most cases limited sonographic examination are appropriate only when a prior complete examination is on record.


Specialized Examination: A detailed anatomic examination is performed when an anomaly is suspected on the basis of history, biochemical abnormalities, or the results of either the limited or standard scan. Other specialized examinations might include fetal doppler ultrasound, biophysical profile, fetal echocardiogram, or additional biometric measurements.


Institute for Clinical Systems Improvement (ICSI)

2012 The Institute for Clinical Systems Improvement (ICSI) Health Care Guideline for Routine Prenatal Care, states three dimensional (3-D) and four dimensional (4-D) ultrasound is considered investigational and is not routinely recommended at this time.


Regulatory Status

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.


Prior Approval:

Not applicable



The use of three dimensional (3-D), four dimensional (4-D), or five dimensional (5-D) fetal ultrasounds in maternity care is considered investigational for all indications.


Although three dimensional (3-D), four dimensional (4-D) and five dimensional (5-D) ultrasound may provide improved imaging for certain areas of the fetal anatomy and abnormalities, it has not been demonstrated in clinical studies to alter management over standard two-dimensional (2-D) ultrasounds such that clinical outcomes are improved. Additional studies are needed to support this technology as a replacement for standard 2-D ultrasound. The evidence is insufficient to determine the effects of this technology on net health outcomes.


Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.

  • 76376 and 76377 may be used for 3-D fetal ultrasound
  • 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independing workstation.
  • 76377 requiring image postprocessing on an independent workstation
  • 76499 Unlisted diagnostic radiographic procedure (when specified as 4-D and 5-D fetal ultrasound)


Selected References:

  • The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
  • 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
  • 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.
  • Merz E & Abramowicz JS. 3D/4D ultrasound in prenatal diagnosis: is it time for routine use? Clin Obstet Gynecol. 2012 Mar;55(1):336-51.
  • Clayton DB & Brock JW 3rd. Prenatal ultrasound and urological anomalies. Pediatr Clin North Am. 2012 Aug;59(4):739-56.
  • Kirk E. Ultrasound in the diagnosis of ectopic pregnancy. Clin Obstet Gynecol. 2012 Jun;55(2):395-401.
  • Society for Maternal Fetal Medicine (SMFM), Coding Committee. White Paper on Ultrasound Code 76811. Announcements. Washington, DC: SMFM; revised May 26, 2012.
  • National Institute of Health and Clinical Excellence (NICE) Antenatal care, Issued March 2008 last modified: June 2010.
  • Institute for Clinical Systems Improvement, Health Care Guidelines, Routine Prenatal Care. Akkerman D, Cleland L, Croft G, Eskuchen K, Heim C, Levine A, Setterlund L, Stark c, Vickers J, Westby E. Updated July 2012
  • The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion, Number 297, August 2004, Reaffirmed 2012, Nonmedical Use of Obstetric Ultrasonography.
  • American Institute of Ultrasound Medicine (AIUM) Official Statement, Keepsake Fetal Imaging, Approved 4/1/2012.
  • American Institute of Ultrasound Medicine AIUM) 2013 Practice Guideline for Obstetric Ultrasound Examinations.
  • The American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 101. Ultrasonography in Pregnancy. Obstet Gynecol. 2009; 113(2 Pt 1):451-461
  • ACR-ACOG-AIUM-SRU Practice Parameter for the Performance of Obstetrical Ultrasound, Amended 2014.
  • UpToDate. Routine Prenatal Ultrasonography as a Screening Tool. Anna K Sfakianaki M.D., Joshua Copel M.D.. Topic last updated January 1330, 2017.
  • UpToDate. Fetal Growth Restrictions: Diagnosis. Michael Y Divon M.D.. Topic last updated February 7, 2017.
  • UpToDate. Prenatal Diagnosis of the Lethal Skeletal Dysplasias. Phyllis Glanc M.D., FRCPC, David Chitayat M.D., FABMG, FACMG, FCCMG, FRCPC. Topic last updated December 20, 2016.
  • UpToDate. Ultrasonography of Pregnancy of Unknown Location. Tejas S. Mehta M.D., MPH. Topic last updated November 20, 2015.
  • Whitworth M, Bricker L, Neilson JP. et. al. Ultrasound for fetal assessment in pregnancy. Cochrane Database Syst Rev. 2010 Apr 14; (4): CD007058. PMID 20393955
  • Whitworth M, Bricker L, Mullan C. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev 2015 Jul 14;7: CD007058. PMID 2617896
  • Benacerraf BR, Shipp TD, Bromley B. Three-dimensional US of the fetus: volume imaging. Radiology 2006 Mar 238(3):988-96. PMID 16424249
  • Yagel S, Cohen SM, Messing B, et. al. Three-dimensional and four-dimensional ultrasound application in fetal medicine. Curr Opin Obstet Gynecol 2009 Apr:21(2):167-74. PMID 19996869
  • American Academy of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 175 Ultrasound in Pregnancy. Obstetrics and Gynecology December 2016 Volume 128 Issue 6 p e241-e256
  • Hur H, Kim YH, Cho Hy et. al. Feasibility of three-dimensional reconstruction and automated measurement of fetal long bones using 5D long bone. Obstet Gynecol Sci 2015;58(4):268-276
  • Laban M, Alanwar AA, Etman MK, et. al. Five-dimensional long bones biometry for estimation of femur length and fetal weight at term compared to two-dimensional ultrasound: a pilot study. J Matern Fetal Neonatal Med. 2017:1-7
  • Rizzo G, Capponi A, Persico N, 5D CNS+ software for automatically imaging axial, sagittal and coronal planes of normal and abnormal second trimester fetal brains. J Ultrasound Med 2016;35(10):2263-2272
  • Schellpfeffer MA. Ultrasound imaging in research and clinical medicine. Birth Defects Res C Embryo Today 2013;99(2):83-92
  • Vos Fl, Bakker M, de Jong-Pleij EA, et. al. Is 3D technique superior to 2D in Down syndrome screening? Evaluation of six second and third trimester fetal profile markers. Prenat Diagn 2015;35(3):207-213
  • 5D Ultrasound.
  • U.S. Food and Drug Administration. Radiation Emitting Products. Ultrasound Imaging. Updated December 4, 2015.


Policy History:

  • June 2018 - Annual review, Policy revised
  • June 2017 - Annual review, Policy renewed
  • June 2016 - Annual review, Policy revised
  • July 2015 - Annual review, Policy renewed
  • August 2014 - Annual review, Policy revised
  • October 2013 - Annual review, Policy revised
  • December 2012 - Annual review, Policy renewed
  • December 2011 - Annual review, Policy renewed

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.


*CPT® is a registered trademark of the American Medical Association.