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)

In utero repair of myelomeningocele (S2404) may be considered medically necessary under the following conditions:

• The fetus is at less than 26 weeks’ gestation; AND
• Myelomeningocele is present with an upper boundary located between T1 and S1 with evidence of hindbrain herniation.

In utero repair of myelomeningocele is considered investigational in the following situations:

• Fetal anomaly unrelated to myelomeningocele; OR
• Severe kyphosis; OR
• Risk of preterm birth (e.g., short cervix or previous preterm birth); OR
• Maternal body mass index of 35 or more.

Scientific evidence does not demonstrate the efficacy of fetal surgery performed for other indications including but not limited to aqueductal stenosis or congenital diaphragmatic hernia.

• 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 therefore, is non-covered. A participating, preferred, or network provider can bill the member for these non-covered 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.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

Blue Cross Blue Shield Association. Medical Policy Reference Manual 4.01.10. Fetal Surgery for Prenatally Diagnosed Malformations. 12/15/2000, 02/25/2004, 6:2007. 3:2011.

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.

Danzer E, Finkel RS, Rintoul NE, et al. Reversal of hindbrain herniation after maternal-fetal surgery for myelomeningocele subsequently impacts on brain stem function. Neuropediatrics. 2008;39(6):359-362.

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(1):47-53.

McElhinney DB, Marshall AC, Wilkins-Haug LE, et al. Predictors of technical success and postnatal biventricular outcome after in utero aortic valvuloplasty for aortic stenosis with evolving hypoplastic left heart syndrome. Circulation. 2009;120(15):1482-1490.

Danzer E, Gerdes M, Begbbingotn MW, Bebbington MW, Zarnow DM, Adzick NS, Johnson MP. Preschool neurodevelopmental outcome of children following fetal myelomeningocele closure. Am J Obstet Gynecol. 2010;202(5):450.e1-e9.

Fayoux P, Hosana G, Devisme L, et al. Neonatal tracheal changes following in utero fetoscopic balloon tracheal occlusion in severe congenital diaphragmatic hernia. J Pediatr Sur. 2010;45(4):687-692.

Adzick NS, Thom EA, Spong CY, et al. A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med. 2011 Feb 9. [Epub ahead of print]