Medicare Advantage

Medical Policy

Title:

Abortion

Policy #:

MA11.010d

Policy

Abortions are covered and eligible for reimbursement consideration by the Company when any of following requirements are met:

If the pregnancy is the result of an act of rape or incest.
In the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a professional provider, place the woman in danger of death unless an abortion is performed.

Abortions performed for any other indication are considered not covered and, therefore, not eligible for reimbursement.

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

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, abortion is covered under the medical benefits of the Company’s Medicare Advantage products when the coverage criteria listed in this medical policy are met.

For Medicare Advantage members, certain drugs are available through either the member's medical benefit (Part B benefit) or pharmacy benefit (Part D benefit), depending on how the drug is prescribed, dispensed, or administered. This medical policy only addresses instances when medical abortion drugs are covered under a member's medical benefit (Part B benefit). It does not address instances when medical abortion drugs are covered under a member’s pharmacy benefit (Part D benefit).

Description

Abortion is defined as the expulsion or extraction of the products of conception from the uterus prior to the state of viability. Abortions are classified as elective or non-elective.

References

Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD). 140.1: Abortion. [CMS Web site]. 06/19/06. Available at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=127&ncdver=2&keywordtype=starts&keyword=abortion&bc=0. Accessed February 15, 2024.

Coding

CPT Procedure Code Number(s)

59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

Z33.2 Encounter for elective termination of pregnancy

HCPCS Level II Code Number(s)

S0199	Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion) except drugs
S2260	Induced abortion, 17 to 24 weeks
S2265	Induced abortion, 25 to 28 weeks
S2266	Induced abortion, 29 to 31 weeks
S2267	Induced abortion, 32 weeks or greater

THE FOLLOWING CODES ARE USED TO REPRESENT MEDICATIONS ASSOCIATED WITH NON-SURGICAL ABORTIONS:


J8610	Methotrexate; oral, 2.5 mg
J8611	Methotrexate (jylamvo), oral, 2.5 mg
J8612	Methotrexate (xatmep), oral, 2.5 mg
J9255	Injection, methotrexate (accord) not therapeutically equivalent to J9260, 50 mg
J9260	Injection, methotrexate sodium, 50 mg
S0190	Mifepristone, oral, 200 mg
S0191	Misoprostol, oral, 200 mcg

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

Modifier G7 Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening

Coding and Billing Requirements

The G7 modifier should be reported with the appropriate CPT and/or HCPCS code.

Cross Reference

Policy History

Version Effective Date:

7/1/2024

Version Issued Date: