Ultrasound in Pregnancy

This policy covers diagnostic obstetric ultrasound in pregnancy—including standard first‑trimester (CPT 76801) and second/third‑trimester (CPT 76805) scans, detailed anatomic ultrasound (CPT 76811), and transvaginal ultrasound (CPT 76817) for indications such as dating, fetal number and viability, placental location, suspected fetal anomaly, fetal growth restriction, multifetal assessment, and cervical length evaluation. Ultrasounds must be medically indicated and documented; coverage is generally limited to one standard first‑trimester and one standard second/third‑trimester scan and one detailed anatomic scan per pregnancy (with limited exceptions), TVU frequency and gestational windows are restricted, and nonmedical uses (3D/4D, fetal‑sex/keepsake imaging) and routine or repeat unindicated exams are not covered.

"Determination of gestational age"

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