OB Ultrasound Imaging Guidelines

This policy covers obstetrical ultrasound imaging services—including general and detailed fetal/anatomic scans, first- and second‑trimester screening, assessments for uncertain dates, IUD localization, infertility/ART monitoring, and evaluation of vaginal bleeding, abdominal pain, ectopic/molar pregnancy, and fetal aneuploidy/anomaly screening—for pregnant patients or those with a confirmed positive pregnancy test. Major requirements/limitations: a prior history/physical and specific documentation are required, obstetrical CPT codes may only be used with confirmed pregnancy (non‑obstetrical pelvic codes are inappropriate), many studies have defined gestational timing windows (e.g., fetal anatomy 18–22 weeks; detailed first‑trimester 12w0d–13w6d; certain codes ≥16 weeks), and atypical or unaddressed presentations require physician review and are not automatically covered.

"A penta screen (quad screen markers + hyperglycosylated hCG) may be done in lieu of a quad screen."