84112
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- No specific documentation requirements or medical necessity documentation checklist is provided in this CPB.
- Background discussion references standard clinical diagnostic methods (history, physical examination, sterile speculum exam, nitrazine, ferning, ultrasound, and indigo carmine amnio-dye test as the definitive test) but the policy does not state required documentation elements for coverage or payment.
- Documentation that the patient is symptomatic for preterm labor (i.e., presenting with signs/symptoms of preterm labor or threatened preterm labor).
- Record of test type and result (e.g., fFN positive/negative; PAMG-1, pIGFBP-1, phIGFBP-1, PartoSure, qfFN quantitative values where applicable).
Key Coverage Criteria
- ICD-10 diagnoses covered if selection criteria are met: O47.00 - O47.9 (False [threatened] labor).
- ICD-10 diagnoses covered if selection criteria are met: O60.00 - O60.03 (Preterm labor without delivery).
- ICD-10 diagnoses covered if selection criteria are met: Z87.51 (Personal history of pre-term labor).
- Symptomatic pregnant women with suspected preterm labor when ALL of the following characteristics are present: Amniotic membranes intact; Cervical dilatation is minimal (less than 3 cm); Sampling is performed no earlier than 24 weeks, 0 days and no later than 34 weeks, 6 days of gestation.
- Use of the fetal fibronectin (fFN) immunoassay to help assess risk of imminent preterm delivery (noting that a negative test has a maximal negative predictive value of approximately 96% for not delivering within the next 2 weeks).
- Situations in which results are available quickly enough (generally considered to be under 4 hours) so that the results can assist in decisions concerning the immediate care of pregnant women (the policy states: “If the test is to be clinically useful, the results must be available from the laboratory in a timely manner (generally considered to be under 4 hours) so that the test can effect decisions concerning the immediate care of the patient.”).
4 Active Policies
AETNA-CPB-0757 — Non-Invasive Fetal Membranes Rupture Tests
AETNA-CPB-0166 — Fetal Fibronectin, Inflammatory Biomarkers, and Salivary Hormone Testing for Preterm Labor
ANTHEM-LAB.00029 — LAB.00029 Rupture of Membranes Testing in Pregnancy
REGENCE-LAB57 — Placental Rapid Immunoassay for Detection of Fetal Membrane Rupture
Related Codes
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