First trimester ultrasound studies
Obstetrical ultrasound studies performed in the first trimester (codes 76801, 76802) by either the attending obstetrician or another health care professional (e.g., ultrasonographer, radiologist) are considered medically necessary in the following situations.

• abnormal findings on previous ultrasound
• absence of fetal heart tones
• adnexal mass
• advanced maternal age
• benign essential hypertension
• carcinoma of cervix uteri
• early pregnancy with pain
• ectopic pregnancy
• fever
• habitual aborter
• hemoperitoneum
• hemorrhage in early pregnancy
• history of greater than 1 loss in 1st trimester
• history of previous cesarean section
• history of uterine abnormality
• hyperemesis gravidarum with metabolic disturbance, antepartum
• incompetent cervix
• leukocytosis
• missed abortion
• molar pregnancy/hydatidiform mole
• other antepartum hemorrhage (antepartum or intrapartum, associated with trauma, uterine leiomyoma)
• other known or suspected fetal abnormality, not elsewhere classified
• other multiple pregnancy with fetal loss and retention of one or more fetus(es)
• other specified multiple pregnancy
• pain, unilateral or generalized
• pregnancy with history of in utero procedure during previous pregnancy
• pregnancy with hypertension
• quadruplet pregnancy
• quadruplet pregnancy with fetal loss and retention of one or more fetus(es)
• spotting early in pregnancy
• syncope (hypovolemic)
• tenderness without rebound
• to determine gestational age when the patient is unsure of the date of the last menstrual period due to hormonal medications, or a medical condition that can result in anovulation and/or irregular menstrual cycles
• triplet pregnancy
• triplet pregnancy with one or two fetal loss
• tumors of body of uterus
• twin pregnancy
• twin pregnancy with one fetal loss
• unspecified multiple gestation

The above criteria for first trimester ultrasound studies also applies to transvaginal obstetrical ultrasound studies (code 76817) when they are performed in the first trimester.

Obstetrical ultrasound studies performed in the first trimester for other diagnoses or conditions are considered not medically necessary.

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.

The American College of Obstetrics-Gynecology describes the following factors that should typically be evaluated during a first trimester ultrasound study. 

• The uterus, including the cervix, and adnexa should be evaluated for the presence, location and size of adnexal masses or a gestational sac. If a gestational sac is seen, it should be evaluated for the presence or absence of a yolk sac or embryo and its location documented. (Caution should be used in presumptively diagnosing a gestational sac in the absence of a definite embryo or yolk sac. Without these findings, intrauterine fluid collection could represent a pseudogestational sac associated with an ectopic pregnancy.)
• The crown-rump length should be recorded when possible. The crown-rump length is a more accurate indicator of gestational (menstrual) age than is mean gestational sac diameter. However, the gestational sac diameter may be recorded when an embryo is not identified.
• Embryonic or fetal anatomy should be assessed according to gestational age. 
• Presence or absence of cardiac activity should be reported. 
• Fetal number should be reported. 
• Amnionicity and chorionicity should be documented for all gestation(s) when possible.

Obstetrical ultrasound prior to abortion
A medically necessary obstetrical ultrasound prior to an abortion is reimbursable. The medical necessity for the service must be documented in the patient's records.

Description

Obstetrical ultrasound is a highly developed technique capable of detecting many fetal structural and functional abnormalities. It is used in detecting ectopic pregnancy and multiple pregnancy, assessing fetal life and function, diagnosing physical anomalies, and guiding physicians in their efforts to treat the fetus.

Codes 76801 and 76802 include determination of the number of gestational sacs and fetuses, gestational sac/fetal measurements appropriate for gestation (< 14 weeks 0 days), survey of visible fetal and placental anatomic structure, qualitative assessment of amniotic fluid volume/gestational sac shape and examination of the maternal uterus and adnexa.

Codes 76805 and 76810 include determination of number of fetuses and amniotic/chorionic sacs, measurements appropriate for gestational age (> or = 14 weeks 0 days), survey of intracranial/spinal/abdominal anatomy, 4 chambered heart, umbilical cord insertion site, placenta location and amniotic fluid assessment and, when visible, examination of maternal adnexa.

Codes 76811 and 76812 include all elements of codes 76805 and 76810 plus detailed anatomic evaluation of the fetal brain/ventricles, face, heart/outflow tracts and chest anatomy, abdominal organ specific anatomy, number/length/architecture of limbs and detailed evaluation of the umbilical cord and placenta and other fetal anatomy as clinically indicated.

The ultrasound report should document the results of the evaluation of each element described above or the reason for non-visualization.

Code 76815 represents a focused “quick look” exam limited to the assessment of one or more of the elements listed in code 76815.

Code 76816 describes an examination designed to reassess fetal size and interval growth or reevaluate one or more anatomic abnormalities of a fetus previously demonstrated on ultrasound, and should be reported once for each fetus requiring reevaluation using modifier ‘-59’ for each fetus after the first.

Code 76817 describes a transvaginal obstetric ultrasound performed separately or in addition to one of the transabdominal examinations described above.

Code 76830 should be used to report transvaginal examinations performed for non-obstetrical purposes.

Refer to Medical Policy Bulletin X-51 for information on the coverage of fetal nuchal translucency thickness measurement performed in the first trimester to detect chromosomal abnormalities and congenital defects (codes 76813, 76814). 

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.

Long-Term Prognosis of Pregnancies Complicated by Slow Embryonic Heart Rates in the Early First Trimester, Journal of Ultrasound Medicine, Vol. 18, August 1999

American College of Obstetrics-Gynecology Practice Bulletin, Number 101, issued 02/2009.