OB Ultrasound Imaging Guidelines

This policy covers obstetrical ultrasound imaging for a wide range of prenatal indications including dating/uncertain LMP, IUD localization, infertility and ART/IVF pregnancies, vaginal bleeding/abdominal pain, ectopic and spontaneous abortion evaluation, fetal aneuploidy and anomaly screening, routine and detailed anatomic scans, and other pregnancy-related clinical scenarios. Major limitations/requirements include documentation of a positive pregnancy test or clinical evidence of pregnancy (fetal heart tones) and an initial clinical evaluation prior to imaging, prohibition of ultrasound solely for sex determination or keepsake pictures, physician review for atypical presentations, and specific CPT coding, frequency and modality restrictions (e.g., transvaginal vs transabdominal codes and add-on codes for multiple fetuses).

"This tool addresses common symptoms and symptom complexes."