OB Ultrasound Imaging Guidelines

This policy covers obstetrical ultrasound imaging for pregnancy-related evaluations—including dating/uncertain LMP, IUD localization, infertility/ART pregnancies, vaginal bleeding/abdominal pain, suspected ectopic or miscarriage, fetal aneuploidy/anomaly screening, and multiple gestations. Major limitations/requirements include documented positive pregnancy test or clinical evidence for authorization, physician review for atypical presentations, prohibition of nonmedical uses (sex determination only or keepsake images), and adherence to specified CPT coding, gestational timing, and technical requirements (e.g., real‑time frame rates and add‑on code rules).

"This tool addresses common symptoms and symptom complexes."

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