SONOGRAM PREGNANCY SERIAL

Ultrasonography in pregnancy should be performed only when there is a valid medical indication. This policy is based in part on The American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin on Ultrasonography in Pregnancy and guidelines fromВ the Society for Maternal-Fetal Medicine (SMFM). See also: CPB 0106 - Fetal Echocardiography and Magnetocardiography. Detailed ultrasound fetal anatomic examination is not considered medically necessary for routine screening of normal pregnancy, or in the setting of maternal idiopathic pulmonary hemosiderosis.ДЄetna considers three-dimensional (3D) and four-dimensional (4D)В fetal ultrasounds experimental and investigational because of a lack of evidence that 3D and 4D ultrasounds alter management over standard two-dimensional (2D) ultrasounds such that clinical outcomes are improved.ДЇootnote1*Assisted Reproductive Technology (ART) is a form of complex infertility treatment where the egg and sperm are fertilized outside the body and the resulting embryo is transferred back into the uterus.В The most well-recognized forms of ART include in-vitro fertilization (IVF), frozen embryo transfers (FET), and intra-cytoplasmic sperm injection (ICSI).ДЇor AetnaвЂ™s policy on first trimester ultrasonographic assessment of fetal nuchal skinfold thickness, see CPB 0282 - Noninvasive Down Syndrome Screening. There is inadequate evidence of the clinical utility of detailed ultrasound fetal anatomic examination for indications other than evaluation of suspected fetal anatomic abnormalities.

SONOGRAM PREGNANCY SERIAL

More thanВ 1 detailed ultrasound fetal anatomic examination per pregnancy per practice is considered experimental and investigational, as there is inadequate evidence of the clinical utility of multiple serial detailed fetal anatomic ultrasound examinations during pregnancy.ДЄetna considers detailed ultrasound fetal anatomic examination experimental and investigational for all other indications including routine evaluation of pregnant women who are on bupropion (Wellbutrin) or levetiracetam (Keppra), pregnant women with low pregnancy-associated plasma protein A, pregnant women with myasthenia gravis, and pregnant women who smoke or abuse cannabis.

Use of detailed fetal US at 20 weeks based on previous pregnancy with a child with DiGeorge syndrome.

To diagnose / evaluate uterus didelphys.

To evaluate the fetus of a mother who has a bicornuate uterus orВ uterus didelphys.

Previous pregnancy with a fetus that had an ultrasound detectable congenital anomaly associated with an elevated risk of recurrence in the current pregnancy or.

Pregnancy in woman with untreated or inadequately treated syphilis or.

Known or suspected exposure to Zika virus or.

Obesity (prepregnancy body mass index В of 30 kg/m 2 or more)В complicating pregnancy or.

Pregnancies resulting from advanced reproductive technology (ART) Footnote1* or.

Anatomic abnormalities due to genetic conditions (see attached ICD-10 coding) or.

Abnormal serum markers screeningВ for fetal aneuploidy (triple or quad screening) (see CPB 464 - Serum and Urine Marker Screening for Fetal Aneuploidy) or.

If there are known or suspected fetal anatomic abnormalities, including:

Shortened long bones (femur or humerus) or.

Increased nuchal translucency (fetal nuchal translucency measurement of 3.0 mm or greater in the first trimester) or.To evaluate fetuses with soft sonographic markers ofВ aneuploidy:.To evaluate fetuses with single umbilical artery (SUA) or.To evaluate the fetus for amniotic band syndrome (also known as amniotic constriction band syndrome) or.Aetna considers ultrasounds not medically necessary if done solely to determine the fetal sex or to provide parents with a view and photograph of the fetusДЄetna considers aВ fetal ultrasound with detailed anatomic examination medically necessary for the following indications:

Sonogram pregnancy