O00.91 — Unspecified ectopic pregnancy with intrauterine pregnancy
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clear clinical indication and the specific diagnostic question for the ultrasound
- Documentation of ultrasound findings relevant to the indication (e.g., gestational age, fetal number, viability, placental location)
- Clinical documentation of history, laboratory abnormalities, or clinical examination supporting suspected anomaly.
- Documentation of suspicious findings from a limited or standard ultrasound when 76811 is performed for follow-up.
Key Coverage Criteria
- Evaluation of germ cell tumors;or
- Testicular cancer or suspicious testicular mass;or
- Ovarian cancer;or
- Pelvic mass;or
- Mediastinal mass;or
- Retroperitoneal mass;or
3 Active Policies
AMBETTER-CP.MP.38 — Ultrasound in Pregnancy
ANTHEM-CG-LAB-27 — CG-LAB-27 Human Chorionic Gonadotropin Testing
ANTHEM-CG-RAD-26 — CG-RAD-26 Maternity Ultrasound in the Outpatient Setting
Related Codes
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