Amnioreduction may be considered medically necessary as a treatment of twin-twin transfusion syndrome. Procedure code 59001 (Amniocentesis; therapeutic amniotic fluid reduction; includes ultrasound guidance) should be used to report this service.

Laser coagulation therapy may be considered medically necessary as a treatment of twin-twin transfusion syndrome. Procedure code S2411 (Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome) should be used to report this service.

Laser therapy may be preceded by either angiography or doppler sonography in order to identify target vessels for laser therapy. There are no specific procedure codes for doppler sonography or angiography of the placenta; therefore, if these services are performed, they should be reported using the following NOC codes:

• 76499  diagnostic radiologic procedure
  (Use this code to report the angiography)
  
  
• 76999  ultrasound procedure
  (Use this code to report the doppler sonography)

Services reported for any other condition will be denied as not medically necessary.  Effective January 26, 2009, a participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Description

Twin-twin transfusion syndrome (TTTS) is a relatively common, yet severe complication that occurs with identical twins. It is often a lethal condition, accounting for a significant number of perinatal deaths overall. The pathophysiology of twin-twin transfusion syndrome is not fully understood, but the primary defect is thought to be abnormal formation of the blood vessels in the placenta. This causes blood to flow disproportionately from one fetus to the other through connecting blood vessels within their shared placenta. As a result, one fetus, the recipient twin, gets too much blood, causing overload of the cardiovascular system. This can lead to heart failure. The other fetus, or donor twin, does not receive enough blood, causing growth restriction and anemia. The circulatory abnormality in the placenta can lead to the formation of excess amniotic fluid around the recipient twin, while too little amniotic fluid surrounds the donor twin. Prenatal management strategies are aimed at relieving the excess amniotic fluid and/or at correction of the underlying vascular abnormalities in the shared placenta.

Selection of treatment options for TTTS presenting before birth is controversial. Most therapies include expectant management, medical therapy, delivery of the compromised twin, selective feticide, or septostomy. Outcomes from these options has been disappointing. Two treatments – serial amnioreduction and fetoscopic laser ablation of anastomotic vessels are currently undergoing active investigation.

Amnioreduction is a variant of amniocentesis in which amniotic fluid is removed in order to restore normal fluid volume.

Fetoscopic laser therapy is designed to correct the underlying abnormality by separating the two fetal circulations. Refinements of laser therapy have focused on the selective ablation of those few arteriovenous anastomoses causing disease. Specific anastomoses can be targeted using angiography, doppler ultrasonography, or direct fetoscopic visualization.

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 4.01.12, Treatment of Twin-Twin Transfusion Syndrome with Amnioreduction and/or Fetoscopic Laser Therapy, 12/15/2000

National Blue Cross Blue Shield Association TEC Assessment, Treatment of Twin-Twin Transfusion Syndrome (TTTS) with Aggressive Amnioreduction and/or Fetoscopic Laser Therapy, Vol. 15, No.16, December 2000