Use of detailed fetal US at 20 weeks based on previous pregnancy with a child with DiGeorge syndrome.įootnote1*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.

To diagnose / evaluate uterus didelphys or.

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

Previous pregnancy with a fetus that had an omphalocele or other 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 of 30 kg/m2 or more) 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 screening for fetal aneuploidy (triple or quad screening) (see CPB 0464 - Serum and Urine Marker Screening for Fetal Aneuploidy) or.When 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 of 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.Fetal ultrasound with detailed anatomic examination for any of the f ollowing indications:.

Ultrasounds are considered not medically necessary if done solely to determine the fetal sex or to provide parents with a view and photograph of the fetus.This Clinical Policy Bulletin addresses ultrasound for pregnancy.Īetna considers the following indications medically necessary unless otherwise stated: Number: 0199 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References

15 week fetus 3d ultrasound