59897
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Clinical documentation demonstrating that ALL specific indication criteria are met (examples below) must be included in the medical record and submitted with requests/claims
- For myelomeningocele repair: documentation of singleton pregnancy; imaging showing myelomeningocele with upper boundary between T1 and S1; evidence of hindbrain herniation on imaging; gestational age at time of procedure (≥19.0 and <26 weeks); documented normal fetal karyotype
- For TTTS laser coagulation: documentation of fetal gestational age (<26 weeks); evidence of polyhydramnios in the recipient fetus and oligohydramnios in the donor fetus; Doppler study results showing abnormal blood flow in one or both fetuses
- For fetal lobectomy (CPAM/CCAM): documentation of fetal hydrops and imaging describing large multicystic or predominantly solid pulmonary lesions
Key Coverage Criteria
- myelomeningocele repair when ALL of the following criteria are met: singleton pregnancy; myelomeningocele with the upper boundary of the lesion located between T1 and S1; evidence of hindbrain herniation; gestational age ≥ 19.0 and <26 weeks; normal fetal karyotype
- nonselective or selective fetoscopic laser coagulation for severe twin-to-twin transfusion syndrome (TTTS) when ALL of the following criteria are met: fetal gestational age of less than 26 weeks; evidence of polyhydramnios in the recipient fetus; donor fetus is oligohydramniotic; evidence of abnormal blood flow documented by Doppler studies in one or both fetuses
- fetal lobectomy for congenital pulmonary airway malformation (CPAM)/congenital cystic adenomatoid formation (CCAM) when BOTH of the following criteria are met: evidence of fetal hydrops; presence of large and multicystic or predominantly solid lesions
- fetoscopic endoluminal tracheal occlusion (FETO) for left congenital diaphragmatic hernia when ALL of the following criteria are met: singleton pregnancy; fetal gestational age of less than 30 weeks; severe pulmonary hypoplasia defined as a quotient of the observed-to-expected lung-to-head ratios of less than 25%; no other major structural or chromosomal defects
- CPT 59897 (Unlisted fetal invasive procedure, including ultrasound guidance, when performed) is considered medically necessary when the applicable policy clinical criteria above are met
- Maternal contraindications to fetoscopic surgery or severe medical conditions that would make fetal intervention riskful;and
8 Active Policies
AMBETTER-CP.MP.129 — Fetal Surgery in Utero for Prenatally Diagnosed Malformations
CIGNA-0175 — Fetal Surgery - (0175)
ANTHEM-CG-SURG-121 — CG-SURG-121 Fetal Surgery for Prenatally Diagnosed Malformations
BCBSIL-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations
BCBSMT-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.