Mountain State Medical Policy Bulletin
Section: Maternity
Number: U-7
Topic: Fetal Surgery for Prenatally Diagnosed Malformations
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Fetal surgery is covered for the following conditions:

  • vesico-amniotic shunting (59076) as a treatment of urinary tract obstruction, (S2401)
  • either open in utero resection of malformed pulmonary tissue or placement of a thoraco-amniotic shunt (59076) as a treatment of either congenital cystic adenomatoid malformation (S2402)or extralobar pulmonary sequestration (S2403)
  • in utero repair of sacrococcygeal teratoma (S2405)

Scientific evidence does not demonstrate the efficacy of fetal surgery performed for other indications including but not limited to myelomeningocele (653.73), aqueductal stenosis (742.3), or congenital diaphragmatic hernia (756.6). Report fetal surgery for myelomeningocele with procedure code S2404. Fetal surgery for aqueductal stenosis should be reported with code S2409. Fetal surgery for congenital diaphragmatic hernia using temporary tracheal occlusion should be reported with procedure code S2400. Fetal surgery for non-approved conditions is considered experimental/investigational and is not covered. A participating, preferred, or network provider can bill the member for these experimental/investigational services.

Description

Most fetal anatomic malformations are best managed after birth. However, advances in methods of prenatal diagnosis, particularly prenatal ultrasound, have led to a new understanding of the natural history and physiologic outcomes of certain congenital anomalies. Fetal surgery is the logical extension of these diagnostic advances, related in part to technical advancement in anesthesia, tocolysis, and hysterotomy.

Fetal surgery typically involves opening the gravid uterus (with either a traditional Cesarean surgical incision or through single or multiple fetoscopic port incisions), surgically correcting a fetal abnormality, and returning the fetus to the uterus and restoring uterine closure.

Fetal surgery is a specialized technique that requires a multidisciplinary approach.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

59076S2400S2401S2402S2403S2404
S2405S2409    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

02/2002, Fetal surgery performed in utero is eligible for certain conditions
10/2004, Temporary tracheal occlusion for treatment of congenital diaphragmatic hernia no longer eligible

References

National Blue Cross Blue Shield Association Medical Policy 4.01.10, Fetal Surgery for Prenatally Diagnosed Malformations, 12/15/2000, 02/25/2004

National Blue Cross Blue Shield Association TEC Assessment, In Utero Fetal Surgery for Prenatally Diagnosed Sacrococcygeal Teratoma, Vol. 14, No. 23, February 2000

A Randomized Trial of Fetal Endoscopic Tracheal Occlusion for Severe Fetal Congenital Diaphragmatic Hernia, New England Journal of Medicine, Vol. 349, No. 20, Nov. 13, 2003

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.