S9001 — Home uterine monitor with or without associated nursing services
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
- Documentation that the pregnant woman cannot feel her contractions (required for consideration of medical necessity).
- Gestational age documented as greater than 18 weeks for the general eligibility statement; for the fetal fibronectin pathway gestational age documented as 20 weeks or greater and less than 36 weeks.
- For incompetent cervix: documentation of need for cerclage or signs of cervical incompetence (funneling on valsalva, silent shortening).
- For the positive fetal fibronectin indication: positive fetal fibronectin test result and documentation of progressive cervical changes with cervical length less than 2.5 cm documented by vaginal probe ultrasound, and documentation that this persists despite treatment with multiple tocolytics.
Key Coverage Criteria
- Aetna considers home uterine activity monitoring (HUAM) experimental and investigational.
- In its discretion, Aetna may consider HUAM medically necessary upon review of each circumstance and consideration of any of the following criteria:
- Women with complicated pregnancies who cannot feel their contractions. HUAM may be considered medically necessary on an individual case exception basis for pregnant women with gestational age greater than 18 weeks who cannot feel their contractions and have any of the following complications:
- Incompetent cervix (as documented by need for cerclage or signs of cervical incompetence (funneling on valsalva, silent shortening))
- Presence of risk factors that increase risk of preterm birth: placenta previa with hemorrhage; history of classical caesarean section or deep myomectomy with contractions/cervical change in index pregnancy, such that woman is not able to safely tolerate contractions
- Presence of physiologic or anatomic factors (eg, paralysis, neuromuscular disorders such as muscular dystrophy) which limit the ability to self-detect contractions
1 Active Policy
AETNA-CPB-0127 — Home Uterine Activity Monitoring
Related Codes
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