Q51.11 — Doubling of uterus with doubling of cervix and vagina with obstruction
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documented medical indication for the ultrasound/examination in the medical record (reason for test, clinical question to be answered).
- For detailed fetal anatomic examination: documentation of the specific covered indication (eg, SUA on initial imaging; presence of soft sonographic marker(s) with description; abnormal serum aneuploidy screening results; known or suspected fetal anatomic abnormality; prior pregnancy with omphalocele or other recurrent ultrasound-detectable congenital anomaly; pregnancy resulting from ART; maternal obesity with prepregnancy BMI ≥ 30 kg/m2; known/suspected Zika exposure; pregnancy in woman with untreated or inadequately treated syphilis; previous child with DiGeorge syndrome).
- When increased nuchal translucency is cited as the indication: documentation of fetal nuchal translucency measurement value (first trimester NT ≥ 3.0 mm qualifies per policy).
Key Coverage Criteria
- ICD-10 B06.00 - B06.9 — Rubella [German measles]
- ICD-10 B50.0 - B54 — Malaria
- Fetal ultrasound with detailed anatomic examination when there are known or suspected fetal anatomic abnormalities (including abnormalities suggested by history, laboratory abnormalities, or results of limited/standard ultrasound).
- Fetal ultrasound with detailed anatomic examination to evaluate the fetus for amniotic band syndrome (amniotic constriction band syndrome).
- Fetal ultrasound with detailed anatomic examination to evaluate fetuses with single umbilical artery (SUA).
- Fetal ultrasound with detailed anatomic examination to evaluate fetuses with soft sonographic markers of aneuploidy, including: absent or hypoplastic nasal bone; choroid plexus cyst; echogenic bowel; echogenic intracardiac focus; fetal pyelectasis; increased nuchal translucency (fetal nuchal translucency measurement of 3.0 mm or greater in the first trimester); shortened long bones (femur or humerus).
1 Active Policy
AETNA-CPB-0199 — Ultrasound for Pregnancy
Related Codes
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