CG-RAD-26 Maternity Ultrasound in the Outpatient Setting

Policy addresses outpatient maternity (obstetric) ultrasound. Covered when: one routine anatomy/dating ultrasound per pregnancy; to establish gestational age if clinical dates are uncertain; for suspected/known maternal reproductive tract issues (for example, suspected cervical insufficiency), including cervical length assessment in the 2nd/3rd trimester for those with prior second/early third trimester loss, current preterm labor, or multifetal gestation; and to guide cervical cerclage placement. Not covered for assessment of fetal well-being without indications, for fetal sex determination only, or for keepsake images; routine coverage is limited to one scan unless the above medical indications are present.

"Maternity ultrasound is consideredmedically necessaryforanyof the following:"

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