OB Ultrasound Imaging Guidelines

This policy covers obstetrical ultrasound imaging for evaluation and monitoring of pregnancy—including nuchal translucency and fetal anatomic scans, fetal echocardiography, assessment of fetal growth, placental/cord abnormalities, trauma, and other high‑risk pregnancy indications. It requires clinical evidence of pregnancy (positive test or fetal heart tones), an initial office evaluation with documentation (gestational age, expected delivery date, prior ultrasound results), limits routine imaging in low‑risk pregnancies to one nuchal translucency (CPT 76813) and one fetal anatomic scan (CPT 76805), prohibits sex‑determination or keepsake ultrasounds, and makes additional or advanced studies subject to documented medical necessity and gestational age–specific criteria.

"NO FETAL HEART TONE/DECREASED FEATAL MOVEMENT"

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