P02.8 — Newborn affected by other abnormalities of membranes
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For thoraco-amniotic shunt (TAS) and pleuro-amniotic shunt: ultrasound documentation of fetal pleural effusion/macro-cystic lung lesion and hydrops, gestational age, pre-procedure counseling, and post-procedure imaging showing reduction in effusion/lesion size and hydrops resolution where applicable.
- For fetal cardiac interventions (e.g., FAV): detailed fetal echocardiography demonstrating critical aortic stenosis with echocardiographic predictors of evolving HLHS (e.g., valve z-scores, ventricular dimensions, pressure gradients), gestational age (mid-gestation candidates), multidisciplinary counseling documentation, and plan for postnatal management and follow-up; documentation that center has required expertise and registry/quality reporting where applicable.
- For LUTO and vesico-amniotic shunting: ultrasound documentation of LUTO (megacystis, oligohydramnios), fetal urine studies results if performed (to assess renal prognosis), counseling about perinatal and long-term renal outcomes, technical plan for shunt placement, and follow-up imaging; note need to document risk of shunt displacement/obstruction and plan for neonatal follow-up.
Key Coverage Criteria
- CPT codes covered if selection criteria are met: 59001 (Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance))
- In utero fetal surgery for ablation of anastomotic vessels in acardiac twins
- In utero fetal surgery for insertion of pleuro-amniotic shunt for fetal pleural effusion
- In utero fetal surgery for laser ablation or occlusion of anastomotic vessels in early, severe (stages II to IV) twin-twin transfusion syndrome (see Appendix for staging classification)
- In utero fetal surgery for removal of sacrococcygeal teratoma
- In utero fetal surgery for repair of myelomeningocele
1 Active Policy
AETNA-CPB-0449 — Fetal Surgery In Utero
Related Codes
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