S2405, Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low 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
8 Active Policies
ANTHEM-CG-SURG-121, CG-SURG-121 Fetal Surgery for Prenatally Diagnosed Malformations
ANTHEM-RAD.00012, THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
AMBETTER-CP.MP.129, Fetal Surgery in Utero for Prenatally Diagnosed Malformations
SUR701.016, Fetal Surgery for Prenatally Diagnosed Malformations
BCBSIL-SUR701.016, Fetal Surgery for Prenatally Diagnosed Malformations
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.