CG-SURG-121 Fetal Surgery for Prenatally Diagnosed Malformations

This policy addresses fetal surgery for prenatally diagnosed malformations, specifically vesico-amniotic shunting for fetal urinary tract obstruction. Coverage is medically necessary only when all criteria are met: bilateral obstruction, progressive oligohydramnios, adequate renal function reserve, and no other lethal or chromosomal abnormalities; if these are not met, fetal surgery is not covered. All other applications of fetal surgery, including for aqueductal stenosis, are considered not medically necessary.

"Fetal surgery is consideredmedically necessarywhen ANY of the following criteria sets (I-V) are met:"

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