Notification

Fetal Surgery


Notification Issue Date: 04/04/2018

This version of the policy will become effective 05/07/2018. The policy has been updated to clarify medically necessary coverage of open approach for myelomeningocele repair and add fetoscopic myelomeningocele repair as experimental investigational.

The following CPT code has been added to this policy: 59898

The following ICD-10 CM codes have been added to this policy: O33.7XX0, O33.7XX1, O33.7XX2, O33.7XX3, O33.7XX4, O33.7XX5, O33.7XX9, O36.8910, O36.8911, O36.8912, O36.8913, O36.8914, O36.8915, O36.8919, O36.8920, O36.8921, O36.8922, O36.8923, O36.8924, O36.8925, O36.8929, O36.8930, O36.8931, O36.8932, O36.8933, O36.8934, O36.8935, O36.8939, O36.8990, O36.8991, O36.8992, O36.8993, O36.8994, O36.8995, O36.8999



Medical Policy Bulletin


Title:Fetal Surgery

Policy #:11.00.03j



The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin 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 Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

Fetal surgery is considered medically necessary and, therefore, covered for any of the following conditions when all of the associated criteria are met:
  • Urinary tract obstruction
    • Diagnosis of hydronephrosis due to bilateral urinary tract obstruction
    • Evidence of progressive oligohydramnios (amniotic fluid volume that is less than expected for gestational age)
    • Evidence of adequate renal function, as defined by fetal urinary electrolytes with no other lethal abnormalities or chromosomal defects
  • Congenital cystic adenomatoid malformation (CCAM) or bronchopulmonary and extralobar pulmonary sequestration (EPS)
    • Gestational age of less than 32 weeks with prenatally diagnosed pulmonary lesions
    • Evidence of fetal hydrops (accumulation of fluid in fetal tissues) on serial ultrasound, placentomegaly, and/or the beginnings of maternal mirror syndrome (maternal water retention that can mirror fetal hydropic changes)
  • Sacrococcygeal teratoma (SCT)
    • Gestational age of less than 32 weeks
    • Diagnosis that is documented through fetal echo/ultrasound with an elevated combined cardiac output (evidence of polyhydramnios (excessive amniotic fluid), placentomegaly, or fetal hydrops)
  • Evolving or diagnosed hypoplastic left heart syndrome (HLHS)
    • Gestational age of 22 to 32 weeks
    • Single gestation
    • Diagnosis based on fetal echocardiography
  • Myelomeningocele (MMC) via open surgery
    • MMC at level T1 through S1 with hindbrain herniation. The lesion can extend below S1, but the highest level cannot be outside the T1-S1 range. Lesion level and hindbrain herniation will be confirmed by ultrasound and fetal MRI.
    • Gestational age of less than 26 weeks
    • Single gestation

EXPERIMENTAL/INVESTIGATIONAL

Fetal surgery for the following conditions is considered experimental/investigational and, therefore, not covered because the safety and effectiveness of these services cannot be established by review of the available published peer-reviewed literature:
  • Congenital diaphragmatic hernia (CDH) via in utero balloon tracheal occlusion therapy [fetoscopic endoluminal tracheal occlusion (FETO)]
  • Myelomeningocele via fetoscopic fetal myelomeningocele repair
  • All other prenatally diagnosed malformations not identified above as medically necessary

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

Fetal surgery should be performed by centers experienced in treating the conditions identified above and staffed by professional providers who have been adequately trained in fetal surgery techniques.

Due to the differing benefits and risks of fetal surgery, there may be certain inclusion and exclusion criteria, as well as medically necessary criteria, used by the fetal surgery team, to determine appropriate candidates for fetal surgery.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, fetal surgery is covered under the medical benefits of the Company’s products when medical necessity criteria in the medical policy are met.

However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company. Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

BILLING GUIDELINES

When reporting the ultra-sound-guided balloon septostomy for atrial septal defect (ASD) creation procedure performed for left hypoplastic heart syndrome, report only one of the following codes: S2409 or 59897.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description

Fetal surgery consists of opening the pregnant uterus (with classical Cesarean incision, or through single or multiple fetoscopic port incisions), surgically correcting the fetal abnormality, and returning the fetus to the uterus for completion of gestational development (or restoring uterine closure if the intervention is accomplished without removing the fetus). Because diagnostic and imaging techniques have improved since the first procedures were performed in the early 1980s, there is increasing use of fetal surgery for the early evaluation and treatment of congenital disorders that can endanger prenatal development or lead to severe postnatal damage or even death.

Peer-reviewed literature has been published on the use of fetal surgery for the following conditions:
  • Urinary tract obstruction
  • Congenital cystic adenomatoid malformation (CCAM) and extralobar pulmonary sequestration (EPS)
  • Sacrococcygeal teratoma
  • Evolving or diagnosed hypoplastic left heart syndrome (HLHS)
  • Congenital diaphragmatic hernia
  • Myelomeningocele

Because most conditions are managed in the postnatal period, prenatal interventions for CCAM and EPS are exceptional cases, not standard.

URINARY TRACT OBSTRUCTION

Fetal urinary tract obstruction interferes with normal fetal development. The spectrum of injury to the fetus depends on the type, degree, and duration of the obstruction. Amniotic fluid that protects the baby in the womb is made up chiefly of urine. An obstruction to the flow of urine from the bladder causes urine to back up and injure the kidneys. Oligohydramnios (a low amount of amniotic fluid) can prevent adequate lung development. The most common cause of an obstruction is a narrowing in the urinary tract. A small number of prenatally diagnosed cases of urinary tract obstruction require prenatal intervention. Bilateral obstruction is most often associated with serious conditions such as pulmonary hypoplasia (underdevelopment of lung tissue) secondary to oligohydramnios. Fetuses with bilateral obstruction, oligohydramnios, adequate renal function reserve, and no other lethal or chromosomal abnormality may be candidates for fetal surgery. The most common surgical approach for urinary tract obstruction is vesicoamniotic shunting by means of shunt or stent placement. The shunting procedure bypasses the obstructed urinary tract, permitting fetal urine to flow into the amniotic space. Small case studies have shown improved survival associated with fetal surgery.

CONGENITAL CYSTIC ADENOMATOID MALFORMATION (CCAM) AND EXTRALOBAR PULMONARY SEQUESTRATION (EPS)

CCAM and EPS are the most common congenital cystic lung lesions. They are similar in that both involve the replacement of a normal segment of lung with abnormally developing tissue.

However, the differences between CCAM and EPS are as follows:

CCAMs can have connections to the pulmonary tree and contain air, in which case lesions are cystic structures that are usually confined to one part of the lung and are characterized by overgrowth of the terminal respiratory bronchioles. In other cases, CCAMs can be either a cystic or a solid lung tumor. Type I and II CCAM appear as cystic, fluid-filled masses, whereas type III CCAM appears as a solid mass.

Bronchopulmonary sequestration is a congenital anomaly in which a mass of embryonic lung tissue becomes isolated from the rest of the lung, with the bronchi mass becoming dilated or cystic and unconnected to the bronchial tree. EPS is a form of bronchopulmonary sequestration characterized by masses of nonfunctioning lung tissue believed to arise from aberrant bronchial budding or from supernumerary bronchial buds during embryogenesis. These extralobar segments of lung tissue have no bronchial connection to the main tracheobronchial system, are mostly supplied by an anomalous systemic artery arising from the aorta, and are drained by the pulmonary venous system.

CCAM can be confused with a bronchopulmonary sequestration (BPS), which may present as a solid mass. A CCAM is diagnosed prenatally when an ultrasound shows a cystic or solid lung tumor, whereas, if the ultrasound reveals a systemic arterial blood supply to the mass, the diagnosis of BPS lesions is confirmed.

For fetuses prenatally diagnosed with CCAM or EPS, the medical literature strongly supports prenatal surgery consisting of open in utero resection of the malformed pulmonary tissue or placement of a thoracoamniotic shunt in cases of hydrothorax or large cystic lesions. Fetuses that are at less than 32 weeks gestation may be appropriate for surgical intervention in the following scenarios:
  • Evidence of fetal hydrops (accumulation of fluid in fetal tissues), placentomegaly, and/or the beginnings of maternal mirror syndrome (maternal water retention that can mirror fetal hydropic changes)
  • Gestation with prenatally diagnosed pulmonary lesions
  • Evidence of progressive hydrops (fluid accumulation surrounding internal organs caused by congestive heart failure) on serial ultrasound

The alternative to prenatal intervention for pulmonary lesions is postnatal management. According to the published peer-reviewed literature, postnatal management is associated with a mortality rate near 100 percent when there is fetal hydrops or placentomegaly.

SACROCOCCYGEAL TERATOMA (SCT)
SCT, which is the most common tumor in a newborn, develops at the base of the coccyx (tailbone). It is both a neoplasm with the power of autonomous growth and a malformation composed of multiple tissues that are foreign to the region of origin and lack organ specificity. Postnatal SCT carries a good prognosis, with morbidity and mortality determined largely by the extent of local disease and potential for malignancy. The in utero fetal mortality rate approaches 100 percent when SCT is associated with fetal hydrops, which is related to high-output heart failure secondary to arteriovenous shunting through the tumor. Fetuses at less than 32 weeks gestation and that have evidence of fetal hydrops are candidates for surgery. The published peer-reviewed medical literature includes only case reports of fetal surgery for SCT. However, in utero surgery may result in prenatal resolution of fetal hydrops, healthy long-term survival, and normal development. If fetal hydrops is left untreated, fetal mortality is near certain.

EVOLVING OR DIAGNOSED HYPOPLASTIC LEFT HEART SYNDROME (HLHS)
Critical aortic stenosis or the narrowing of the aortic valve occurs with evolving HLHS. The diagnosis of evolving HLHS can be made by a fetal echocardiography. In utero, an aortic balloon valvuloplasty has been performed to relieve aortic stenosis in an attempt to preserve left ventricular growth and halt the progression to HLHS.

HLHS with intact atrial septum describes the absence of a connection between the left and right atrium. Blood is kept in the left atrium, which can cause lung disease and even profound cyanosis. While in utero, an ultrasound-guided balloon septostomy can be performed to open the atrial septum in an attempt to improve blood flow to the left side of the heart and increase postnatal survival for this condition. Infants born with HLHS have a high mortality rate; death usually occurs after the first week of life. Without treatment, mortality is 100 percent within 2 to 3 weeks after birth. There is general agreement that a small or absent foramen ovale/atrial septal defect (ASD) during fetal development causes reduced blood flow to the left heart and subsequent hypoplasia of the left side of the heart.

A feasibility research study demonstrated that an ultrasound-guided fetal atrial septoplasty, which involves a septal puncture and balloon dilation, is feasible. A positive clinical impact on the development of the left heart and fetal survival has been demonstrated in select cases.

Either of the procedures to treat evolving or diagnosed HLHS should be performed between 22 and 32 weeks gestation.

CONGENITAL DIAPHRAGMATIC HERNIA (CDH)
CDH is a defect in which abdominal organs enter the chest, which may result in hypoplasia of the lungs. CDH varies widely in severity, depending on the size of the hernia and the timing of the herniation. Temporary tracheal occlusion prevents the normal efflux of fetal lung fluid, which in turn enhances positive pressure in the growing lungs, promoting lung growth and reducing abdominal viscera back into the abdominal cavity.

Tracheal occlusion is currently the preferred approach, but only performed under study with an investigational device exemption (IDE) at several institutions. Rather than the tracheal clip, as used in prior years, the approach is to place an intra-tracheal balloon mid-gestation using minimal-access techniques. The results from one nonrandomized comparison of standard postnatal care, with an open tracheal occlusion, and fetoscopic tracheal occlusion, showed a much better survival rate with fetoscopic tracheal occlusion. The effectiveness of treating CDH has not yet been determined; fetal mortality and morbidity remain high. In utero balloon tracheal occlusion therapy for CDH is still being investigated in clinical trials.

MYELOMENINGOCELE (MMC)
Spina bifida is among the most common congenital anomalies of the central nervous system that are compatible with life. The most frequent form is myelomeningocele (MMC), characterized by the extrusion of the spinal cord into a sac filled with cerebrospinal fluid, resulting in lifelong disability. Despite folic acid fortification, the incidence of MMC has stabilized at 3.4 per 10,000 live births in the United States. Liveborn infants with MMC have a death rate of approximately 10 percent. Long-term survivors have major disabilities, including paralysis and bowel and bladder dysfunction. Damage to the spinal cord and peripheral nerves is usually evident at birth and irreversible despite early postnatal surgical repair. The severity of the neurologic disability in the lower limbs is correlated with the level of the injury to the spinal cord.

Children's Hospital of Philadelphia (CHOP), Vanderbilt University, and the University of California at San Francisco performed open maternal-fetal surgery for MMC as part of the Management of Myelomeningocele Study (MOMS), a randomized trial sponsored by the National Institutes of Health (NIH) that took place February 2003 through December 2010. All three institutions have gathered information on fetal surgery for MMC in the context of this trial.

Review of the data from the MOMs trial reported on 158 (of the 183 enrolled) patients. Clinicians who were independent of the surgical teams and blinded (not informed which of the two surgeries a given child received) evaluated the children from the study at 1 year of age and again at 2.5 years of age (30 months). The study identified that prenatal surgery repair of MMC resulted in better neurologic function than repair deferred until after delivery. The study compared outcomes of in utero repair with standard postnatal surgery repair, and compared how many patients in each group required shunt placement following the repair.

At 1 year of age, 40 percent of the children in the prenatal surgery group had received a shunt, compared to 83 percent of the children in the postnatal surgery group. During pregnancy, all the fetuses in the trial had hindbrain herniation. However, at 1 year of age (12 months), one-third (36 percent) of the infants in the prenatal surgery group no longer had any evidence of hindbrain herniation, compared to only 4 percent in the postnatal surgery group. The study concluded that prenatal surgery for MMC reduced the need for shunting and improved motor outcomes at 2.5 years of age (30 months). While the ability to walk depends on the level of the spina bifida lesion, the study found a twofold increase in the proportion of children able to walk without crutches or other assistive devices: 42 percent in the prenatal surgery group compared to 21 percent in the postnatal surgery group.

Research is ongoing into minimally invasive fetoscopic approaches to myelomeningocele repair. To date, published data are limited. A recent retrospective study described experience developing a two-port fetoscopic technique and suggested that maternal-fetal complications may be comparable to those reported with open repair, yet with the potential to achieve vaginal delivery in the index pregnancy and reduced long-term maternal risks. Study limitations included a small sample size and lack of information regarding long-tern neurodevelopmental outcomes. According to the 2017 ACOG Committee Opinion, fetoscopic myelomeningocele repair cannot be recommended outside of an institutional review-board approved setting at a center with an appropriate level of expertise, resources, and research oversight.
References


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Morris RK, Malin GL, Quinlan-Jones E et al. Percutaneous vesicoamniotic shunting versus conservative management for fetal lower urinary tract obstruction (PLUTO): a randomised trial. Lancet. 2013;382(9903):1496-506.

Morris RK, Malin GL, Quinlan-Jones E, et al. The Percutaneous Shunting in Lower Urinary Tract Obstruction (PLUTO) Study and Randomised Controlled Trial. Evaluation of the effectiveness, cost-effectiveness and acceptability of percutaneous vesicoamniotic shunting for lower urinary tract obstruction. Health Technol Assess. 2013;17(59):1-232.

Morris RK, Middleton LJ, Malin GL, et al. Outcome in fetal lower urinary tract obstruction: a prospective registry study. Ultrasound Obstet Gynecol. 2015;46(4):424-31.

Nassr AA, Shazly SA, Abdelmagied AM, et al. Effectiveness of vesico-amniotic shunt in fetuses with congenital lower urinary tract obstruction: An updated systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2017;49(6):696-703.

Oermann CM. Bronchopulmonary sequestration. 11/29/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed January 12, 2018.

Oermann CM. Congenital pulmonary airway (cystic adenomatoid) malformation. 11/14/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed January 12, 2018.

Papadopulos NA, Papadopoulos MA, Kovacs L, et al. Foetal surgery and cleft lip and palate: current status and new perspectives. Br J Plast Surg. 2005; 58(5):593-607.

Pedra SR, Peralta CF, Crema L, et al. Fetal interventions for congenital heart disease in Brazil. Pediatr Cardiol. 2014;35(3):399-405.

Pedreira DA, Zanon N, Nishikuni K, et al. Endoscopic surgery for the antenatal treatment of myelomeningocele: the CECAM trial. Am J Obstet Gynecol. 2016;214(1):111.e1-111.e11.

Peranteau WH, Scott Adzick N, Boelig MM, et al. Thoracoamniotic shunts for the management of fetal lung lesions and pleural effusions: a single-institution review and predictors of survival in 75 cases. J Pediatr Surg. 2015;50(2):301-5.

Rocha LA, Byrne FA, Keller RL, et al. Left heart structures in human neonates with congenital diaphragmatic hernia and the effect of fetal endoscopic tracheal occlusion. Fetal Diagn Ther. 2014;35(1):36-43.

Ruano R, Duarte SA, Pimenta EJdA, et al. Comparison between Fetal Endoscopic Tracheal Occlusion Using a 1.0-mm Fetoscope and Prenatal Expectant Management in Severe Congenital Diaphragmatic Hernia. Fetal Diagnosis and Therapy. 2011;29(1):64-70.

Ruano R, Duarte S, Zugaib M. Percutaneous laser ablation of sacrococcygeal teratoma in a hydropic fetus with severe heart failure--too late for a surgical procedure? Fetal Diagn Ther. 2009;25(1):26-30.

Ruano R, Yoshisaki CT, da Silva MM, et al. A randomized controlled trial of fetal endoscopic tracheal occlusion versus postnatal management of severe isolated congenital diaphragmatic hernia. Ultrasound Obstet Gynecol. 2012;39(1):20-7.

Rychik J, Khalek N, Gaynor JW, et al. Fetal intrapericardial teratoma: natural history and management including successful in utero surgery. Am J Obstet Gynecol. 2016;215(6):780.e1-780.e7.

Schidlow DN, Tworetzky W, Wilkins-Haug LE. Percutaneous fetal cardiac interventions for structural heart disease. Am J Perinatol. 2014;31(7):629-636.

Shan W, Wu Y, Huang G, et al. Foetal endoscopic tracheal occlusion for severe congenital diaphragmatic hernia--a systemic review and meta-analysis of randomized controlled trials. J Pak Med Assoc. 2014;64(6):686-689.

Shue E. Fetal Surgery for Sacrococcygeal Teratoma. [eMedicine Web site]. Updated 8/16/2017. Available at: http://emedicine.medscape.com/article/2109544-overview#showall. Accessed January 12, 2018.

Soni S, Moldenhauer JS, Spinner SS, et al. Chorioamniotic membrane separation and preterm premature rupture of membranes complicating in utero myelomeningocele repair. Am J Obstet Gynecol. 2016;214(5):647.e1-7.

Tubbs RS, Chambers MR, Smyth MD, et al. Late gestational intrauterine myelomeningocele repair does not improve lower extremity function. Pediatr Neurosurg. 2003;38(3):128-132.

Tulipan N, Wellons JC 3rd, Thom EA, et al. Prenatal surgery for myelomeningocele and the need for cerebrospinal fluid shunt placement. J Neurosurg Pediatr. 2015;16(6):613-20.

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Walsh WF, Chescheir NC, Gillam-Krakauer M, et al. Maternal-fetal surgical procedures. Comparative Effectiveness Technical Briefs, No. 5. Rockville (MD): Agency for Healthcare Research and Quality (US) 2011 Apr. Report No. 10(11)-EHC059-EF. Available online at: http://www.ncbi.nlm.nih.gov/books/NBK54520/pdf/TOC.pdf. Accessed January 12, 2018.

White SB, Tutton SM, Rilling WS, et al. Percutaneous in utero thoracoamniotic shunt creation for fetal thoracic abnormalities leading to nonimmune hydrops. J Vasc Interv Radiol. 2014;25(6):889-894.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY
59074, 59076

THE FOLLOWING CODE IS USED TO REPRESENT ULTRASOUND-GUIDED BALLOON SEPTOSTOMY:
59897

EXPERIMENTAL/INVESTIGATIONAL

THE FOLLOWING CODE IS USED TO REPRESENT FETOSCOPIC MYELOMENINGOCELE REPAIR:
59898


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

O33.7XX0 Maternal care for disproportion due to other fetal deformities, not applicable or unspecified

O33.7XX1 Maternal care for disproportion due to other fetal deformities, fetus 1

O33.7XX2 Maternal care for disproportion due to other fetal deformities, fetus 2

O33.7XX3 Maternal care for disproportion due to other fetal deformities, fetus 3

O33.7XX4 Maternal care for disproportion due to other fetal deformities, fetus 4

O33.7XX5 Maternal care for disproportion due to other fetal deformities, fetus 5

O33.7XX9 Maternal care for disproportion due to other fetal deformities, other fetus

O35.0xx0 Maternal care for (suspected) central nervous system malformation in fetus, not applicable or unspecified

O35.0xx1 Maternal care for (suspected) central nervous system malformation in fetus, fetus 1

O35.0xx2 Maternal care for (suspected) central nervous system malformation in fetus, fetus 2

O35.0xx3 Maternal care for (suspected) central nervous system malformation in fetus, fetus 3

O35.0xx4 Maternal care for (suspected) central nervous system malformation in fetus, fetus 4

O35.0xx5 Maternal care for (suspected) central nervous system malformation in fetus, fetus 5

O35.0xx9 Maternal care for (suspected) central nervous system malformation in fetus, other fetus

O35.8xx0 Maternal care for other (suspected) fetal abnormality and damage, not applicable or unspecified

O35.8xx1 Maternal care for other (suspected) fetal abnormality and damage, fetus 1

O35.8xx2 Maternal care for other (suspected) fetal abnormality and damage, fetus 2

O35.8xx3 Maternal care for other (suspected) fetal abnormality and damage, fetus 3

O35.8xx4 Maternal care for other (suspected) fetal abnormality and damage, fetus 4

O35.8xx5 Maternal care for other (suspected) fetal abnormality and damage, fetus 5

O35.8xx9 Maternal care for other (suspected) fetal abnormality and damage, other fetus

O36.8910 Maternal care for other specified fetal problems, first trimester, not applicable or unspecified

O36.8911 Maternal care for other specified fetal problems, first trimester, fetus 1

O36.8912 Maternal care for other specified fetal problems, first trimester, fetus 2

O36.8913 Maternal care for other specified fetal problems, first trimester, fetus 3

O36.8914 Maternal care for other specified fetal problems, first trimester, fetus 4

O36.8915 Maternal care for other specified fetal problems, first trimester, fetus 5

O36.8919 Maternal care for other specified fetal problems, first trimester, other fetus

O36.8920 Maternal care for other specified fetal problems, second trimester, not applicable or unspecified

O36.8921 Maternal care for other specified fetal problems, second trimester, fetus 1

O36.8922 Maternal care for other specified fetal problems, second trimester, fetus 2

O36.8923 Maternal care for other specified fetal problems, second trimester, fetus 3

O36.8924 Maternal care for other specified fetal problems, second trimester, fetus 4

O36.8925 Maternal care for other specified fetal problems, second trimester, fetus 5

O36.8929 Maternal care for other specified fetal problems, second trimester, other fetus

O36.8930 Maternal care for other specified fetal problems, third trimester, not applicable or unspecified

O36.8931 Maternal care for other specified fetal problems, third trimester, fetus 1

O36.8932 Maternal care for other specified fetal problems, third trimester, fetus 2

O36.8933 Maternal care for other specified fetal problems, third trimester, fetus 3

O36.8934 Maternal care for other specified fetal problems, third trimester, fetus 4

O36.8935 Maternal care for other specified fetal problems, third trimester, fetus 5

O36.8939 Maternal care for other specified fetal problems, third trimester, other fetus

O36.8990 Maternal care for other specified fetal problems, unspecified trimester, not applicable or unspecified

O36.8991 Maternal care for other specified fetal problems, unspecified trimester, fetus 1

O36.8992 Maternal care for other specified fetal problems, unspecified trimester, fetus 2

O36.8993 Maternal care for other specified fetal problems, unspecified trimester, fetus 3

O36.8994 Maternal care for other specified fetal problems, unspecified trimester, fetus 4

O36.8995 Maternal care for other specified fetal problems, unspecified trimester, fetus 5

O36.8999 Maternal care for other specified fetal problems, unspecified trimester, other fetus



HCPCS Level II Code Number(s)



MEDICALLY NECESSARY

S2401 Repair, urinary tract obstruction in the fetus, procedure performed in utero

S2402 Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero

S2403 Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero

S2404 Repair, myelomeningocele in the fetus, procedure performed in utero

S2405 Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero

THE FOLLOWING CODE IS USED TO REPRESENT ULTRASOUND-GUIDED BALLOON SEPTOSTOMY:

S2409 Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified

EXPERIMENTAL/INVESTIGATIONAL

THE FOLLOWING CODE IS USED TO REPRESENT TRACHEAL OCCLUSION:

S2400 Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero



Revenue Code Number(s)

N/A



Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.00.03j
05/07/2018This policy has undergone routine review. The policy has been updated to clarify medically necessary coverage of open approach for myelomeningocele repair and added fetoscopic myelomeningocele repair as experimental investigational.

The following CPT code has been added to this policy: 59898

The following ICD-10 CM codes have been added to this policy: O33.7XX0, O33.7XX1, O33.7XX2, O33.7XX3, O33.7XX4, O33.7XX5, O33.7XX9, O36.8910, O36.8911, O36.8912, O36.8913, O36.8914, O36.8915, O36.8919, O36.8920, O36.8921, O36.8922, O36.8923, O36.8924, O36.8925, O36.8929, O36.8930, O36.8931, O36.8932, O36.8933, O36.8934, O36.8935, O36.8939, O36.8990, O36.8991, O36.8992, O36.8993, O36.8994, O36.8995, O36.8999


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 05/07/2018
Version Issued Date: 05/07/2018
Version Reissued Date: N/A



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