OB Ultrasound Imaging Guidelines

This policy covers obstetrical ultrasound imaging services for evaluation and monitoring of pregnancy-related conditions, including dating/uncertain LMP, IUD localization, infertility and ART pregnancies, vaginal bleeding/abdominal pain (including ectopic and miscarriage), recurrent pregnancy loss, and fetal aneuploidy/anomaly screening. Major limitations and requirements include a prior history/physical and a positive pregnancy test or clinical evidence of pregnancy, physician review for atypical presentations and scans <16 weeks (Medical Director review), timing guidance for anatomy survey (optimally 18–22 weeks, after 14 weeks), restriction of nuchal translucency when cfDNA is planned/performed, and exclusions such as sex-determination-only or keepsake imaging, with additional coding, frequency, and "inappropriate use" constraints.

"CPT 76815 'dating' use limited to patients who do not meet gestational age criteria for dating with CPT 76801 or who are too early for an anatomy scan (i."