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, aqueductal stenosis, or congenital diaphragmatic hernia. 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.

National Blue Cross Blue Shield Association Medical Policy 4.01.10, Fetal Surgery for Prenatally Diagnosed Malformations, 12/15/2000, 02/25/2004, 6:2007

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

Maternal-Fetal Surgery for Myelomeningocele; Neurodevelopmental Outcomes at 2 Years of Age, American Journal of Obstetrics and Gynecology, Vol. 194(4),  April 2006

Fetal Lung-to-Head ratio in the Prediction of Survival in Severe Left-Sided Diaphragmatic Hernia Treated by Fetal Endoscopic Tracheal Occlusion (FETO), American Journal of Obstetrics and Gynecology, Vol. 195(6), December 2006

Impact of Maternal-Fetal Surgery for Myelomeningocele on the Progression of Ventriculomegaly in Utero, American Journal of Obstetrics and Gynecology, Vol. 193(3), September 2005

Danzer E, Gerdes M, Bebbington MW, et al. Lower Extremity Neuromotor Function and Short-Term Ambulatory Potential following in utero Myelomeningocele Surgery. Fetal Diagn Ther. 2009;25:47-53.

Danzer E, Johnson MP, Bebbington M, et al. Fetal head biometry assessed by fetal magnetic resonance imaging following in utero myelomeningocele repair. Fetal Diagn Ther. 2007;22:1-6.

Sutton L. Fetal surgery for neural tube defects. National Institute of Health Web site. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2293328&tool=pmcentrez. Accessed July 21, 2009.

Jelin E, Lee H, Tracheal occlusion for fetal congenital diaphragmatic hernia: the US experience, Clin Perinatol. 2009 Jun;36(2):349-61, ix.