O40.1XX0 — Polyhydramnios, first trimester, not applicable or unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Key Coverage Criteria
- Suspected fetal death;
- Assess amniotic fluid volume in post-term gestation.
- Evaluate a pelvic mass that has been detected clinically.
- Maternity ultrasound is consideredmedically necessaryforanyof the following:
- Routine anatomy screen and dating:One ultrasound of a pregnant uterus per member, per routine course of care;Estimate gestational age for individuals with uncertain clinical dates.
- One ultrasound of a pregnant uterus per member, per routine course of care;
2 Active Policies
ANTHEM-RAD.00038 — RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
ANTHEM-CG-RAD-26 — CG-RAD-26 Maternity Ultrasound in the Outpatient Setting
Related Codes
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