Three-dimensional (3D), Four-dimensional (4D), and Five-dimensional (5D) Obstetrical Ultrasound

This policy addresses three‑dimensional (3D), four‑dimensional (4D), and five‑dimensional (5D) obstetrical ultrasound (including 5D viewer software and 4D‑STIC) for prenatal fetal evaluation—particularly for assessment of facial anomalies (e.g., clefts), neural tube defects, skeletal malformations, congenital heart disease evaluation, and specialized research or referral‑center applications. Major limitations: these modalities are considered experimental/investigational and not covered for routine perinatal use due to insufficient high‑quality evidence (policy inactive), so use is generally limited to research or expert centers and is subject to member benefit plan and state regulatory determinations.

"Intended for viewing, analyzing, editing, measuring, and storing 3D obstetric ultrasound data using 5D viewer software"

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