Medical Policy: 04.01.06
Original Effective Date: April 1999
Reviewed: June 2016
Revised: June 2016
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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. This policy addresses the use of 3-D and 4-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.
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 provider 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.
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)
ACR-ACOG-AIUM-SRU Practice Parameter for the Performance of Obstetrical Ultrasound (amended 2014):
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 investigational. 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.
This guideline does not mention or indicate the use of 3D or 4D ultrasound.
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.
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.
The use of three dimensional (3-D) or four dimensional (4-D) fetal ultrasounds is considered investigational for all indications.
Two dimensional (2-D) ultrasound remains the primary method of obstetric imaging. There is insufficient evidence in the peer reviewed medical literature to support the use of three dimensional (3-D) or four dimensional (4-D) ultrasound. Although 3-D and 4-D ultrasound may provide improved imaging for certain areas of the fetal anatomy and abnormalities, it has not been demonstrated in clinical studies to result in improved outcomes or impacts treatment decisions when compared to conventional 2-D ultrasound imaging. Additional studies are needed to support this technology as a replacement for 2D ultrasound. Therefore, the use of 3-D or 4-D ultrasound is considered investigational for all indications.
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*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.