OB Ultrasound Imaging Guidelines

Obstetric ultrasound imaging for evaluation and monitoring of pregnancy-related complaints and conditions, including vaginal bleeding, abdominal/pelvic pain or trauma, ectopic pregnancy, spontaneous abortion, hydatidiform mole, fetal anatomic survey, growth and heart concerns, alloimmunization/parvovirus/hydrops, amniotic fluid abnormalities, abnormal presentation, and other obstetric indications. Authorization requires clinical evidence of pregnancy (positive test or fetal heart tones), follows timing and coding/sequence limits (eg, optimal anatomic survey at 18–22 weeks; limited CPT codes only when a complete study has not been performed; restricted first‑trimester imaging unless cramping/bleeding), excludes nonmedical uses (sex determination or keepsake images), and may require physician or Medical Director review for atypical presentations or advanced imaging.

"OB-11."