OB Ultrasound Imaging Guidelines

This policy covers obstetric ultrasound imaging for evaluation and management of common pregnancy-related symptoms and conditions — e.g., vaginal bleeding, abdominal/pelvic pain or trauma, ectopic pregnancy, spontaneous abortion, hydatidiform mole, abnormal fetal presentation, alloimmunization/fetal anemia, parvovirus exposure, twin complications, fetal hydrops, and amniotic fluid abnormalities. Major limitations/requirements: atypical presentations require physician review; ultrasound requires a positive pregnancy test or clinical evidence of pregnancy (fetal heart tones), is not authorized solely for sex determination or keepsake images, and must follow gestational‑age–based timing and coding rules (single routine anatomy survey optimally at 18–22 weeks; limited vs complete exams only when medically indicated and when a complete study has not already been performed).

"This tool addresses common symptoms and symptom complexes."