S2403 — Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Imaging/diagnostic documentation (prenatal ultrasound) confirming LUTO, CPAM/BPS, pleural effusion/hydrops, or TTTS.
- For TTTS: documentation of Quintero stage, gestational age, and relevant maternal signs and symptoms.
- Documentation that multiple fetal anomalies or chromosomal abnormalities are absent when indicating vesico-amniotic shunting.
- Documentation of provider/facility capability or credentials when specialized technical expertise is required for the procedure.
Key Coverage Criteria
- Maternal contraindications to fetoscopic surgery or severe medical conditions that would make fetal intervention riskful;and
- Fetal surgery is consideredmedically necessarywhen ANY of the following criteria sets (I-V) are met:
- Vesico-amniotic shunting as a treatment of urinary tract obstruction in fetuses whenallthe following conditions are met:Bilateral obstruction;andEvidence of progressive oligohydramnios;andAdequate renal function reserves;andNo other lethal or chromosomal abnormalities.
- Bilateral obstruction;and
- Evidence of progressive oligohydramnios;and
- Adequate renal function reserves;and
7 Active Policies
AMBETTER-CP.MP.129 — Fetal Surgery in Utero for Prenatally Diagnosed Malformations
ANTHEM-CG-SURG-121 — CG-SURG-121 Fetal Surgery for Prenatally Diagnosed Malformations
BCBSIL-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations
BCBSMT-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations
BCBSNM-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations
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