Medical Policy: 04.01.06
Original Effective Date: April 1999
Reviewed: June 2021
Revised: June 2020
This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.
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:
Limitations of 3-D ultrasound of the fetus are as follows:
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 technology in fetal assessment in clinical practice:
Although three- dimensional (3-D), four- dimensional (4-D) and five- dimensional (5-D) 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, 4-D and 5-D ultrasound for a number of fetal abnormalities has not been definitively established. Two-dimensional (2-D) imaging remains the principal diagnostic modality.
Based on the review of the peer reviewed medical literature although three-dimensional (3-D), four-dimensional (4-D) and five-dimensional (5-D) ultrasound may be useful in evaluating abdominal abnormalities such as bowel obstruction, gastroschisis, omphalocele, and wall defects secondary to bands, the advantages compared with two-dimensional ultrasound have not been identified. These ultrasound techniques may also be superior to two-dimensional ultrasound in demonstrating cleft lip or palate and for accurate identification of the level of spine involvement by a neural tube defect, however, the significance of this in terms of improved clinical outcomes has not been demonstrated. Several authors have noted that it is difficult to evaluate the net effect of 3-D, 4-D and 5-D ultrasound on obstetric practice and on outcome. They also note that no comparative studies are available to support the superiority of these ultrasound techniques versus 2-D for evaluation of the central nervous system. Although the uterine cervix in pregnancy has become a focus of 3-D ultrasound, insufficient good data is available to assess fully the additional clinical advantage of 3-D, 4-D and 5-D ultrasound in this context.
In summary, although 3-D, 4-D and 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 in demonstrating that three-dimensional (3-D), four-dimensional (4-D) and five-dimensional (5-D) ultrasounds alter management over standard two-dimensional (2-D) ultrasounds such that clinical outcomes are improved.
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.”
In 2018, AIUM-ACR-ACOG and SRU issued a collaborative practice parameter for the performance of standard diagnostic obstetrical ultrasound examination, this guideline does not mention or indicate the use of 3D, 4D, or 5D ultrasound.
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.
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.
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 not medically necessary 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 two-dimensional (2-D) ultrasound, the significance in terms of improved clinical outcomes has not been demonstrated.
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
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.