59074
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
5.11
Facility
$275.56
Non-Facility
$388.45
Documentation Required
- Gestational age documentation demonstrating <26 weeks for procedures that require early gestation (e.g., laser coagulation, myelomeningocele repair).
- Imaging report documenting myelomeningocele location (upper boundary between T1 and S1) and evidence of hindbrain herniation.
- Fetal karyotype result documented as normal for myelomeningocele repair eligibility.
- Documentation confirming singleton pregnancy.
Key Coverage Criteria
- Vesico-amniotic shunting for bilateral fetal urinary tract obstruction when there is hydronephrosis due to bilateral obstruction, progressive oligohydramnios, adequate fetal renal function, and no other lethal anomalies or chromosomal defects.
- Open in-utero resection of malformed pulmonary tissue or placement of a thoraco-amniotic shunt for congenital cystic adenomatoid malformation (CCAM) or bronchopulmonary sequestration (BPS) when the fetus is ≤32 weeks' gestation and there is fetal hydrops, placentomegaly, and/or maternal mirror syndrome (early severe pre-eclampsia).
- In-utero removal of sacrococcygeal teratoma when the fetus is ≤32 weeks' gestation.
- Evidence of fetal hydrops in the fetus
- Placentomegaly
- Beginnings of severe pre-eclampsia in the mother (maternal mirror syndrome)
5 Active Policies
BCBSIL-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations
BCBSMT-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations
BCBSNM-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations
BCBSOK-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations
SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations
Related Codes
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