Evicore Obstetrical Ultrasound Imaging Guidelines

CLINICAL GUIDELINES OB Ultrasound Imaging Policy Version 3.0 Effective November 15, 2020

eviCore healthcare Clinical Decision Support Tool Diagnostic Strategies: This tool addresses common symptoms and symptom complexes. Imaging requests for individuals with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or individual’s Primary Care Physician (PCP) may provide additional insight.

CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright 2020 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT® book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

Obstetrical Ultrasound Imaging Guidelines Abbreviations and Glossary for OB Ultrasound Imaging Guidelines 6 OB-1: Obstetrical Ultrasound Imaging General Guidelines 7 OB-1.0: Obstetrical Imaging 8 OB-1.1: Required Documentation 8 OB-1.2: Inappropriate Use of OB Ultrasound 8 OB-1.3: Ultrasound Code Selection 8 OB-2: Uncertain Dates 12 OB-2.1: Uncertain Dates/Unknown Last Menstrual Period (LMP) 13 OB-3: Intrauterine Device (IUD) 14 OB-3.1: Locate an Intrauterine Device (IUD) 15 OB-4: Infertility 16 OB-4.1: History of Infertility 17 OB-4.2: Present Pregnancy with ART Treatment (IVF) 17 OB-4.3: Recurrent Pregnancy Loss 17 OB-5: Vaginal Bleeding and/or Abdominal/Pelvic Pain/Cramping 18 OB-5.1: Abdominal/Pelvic Pain 19 OB-5.2: Vaginal Bleeding 19 OB-5.3: Ectopic Pregnancy 19 OB-5.4: Spontaneous Abortion/Threatened/Missed Abortion 20 OB-5.5: Hydatidiform Mole 20 OB-6: Fetal Aneuploidy and Anomaly Screening 21 OB-6.1: First Trimester Screening 22 OB-6.2: Second Trimester Screening 23 OB-7: Fetal Anatomic Scan 24 OB-7.1: Fetal Anatomic Scan 25 OB-7.2: Fetal Anatomic Scan – Follow-up 25 OB-8: Third Trimester Imaging 27 OB-8.1: Third Trimester Imaging – Ultrasound 28 OB-9: High Risk Pregnancy 29 OB-9.0: High Risk General Information 30 OB-9.1: High Risk Group One – Risk Factors 30 OB-9.2: High Risk Group Two – Findings on Ultrasound that May Require Further Imaging 33 OB-9.3: High Risk Group Three – High BMI (>30 kg/m2) 34 OB-9.4: High Risk Group Four – Macrosomia 35 OB-9.5: High Risk Group Five – Zika and COVID-19 Virus 35

______©2020 eviCore healthcare. All Rights Reserved. Page 2 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______Obstetrical Ultrasound ©2020 OB Oligohydramnios/Polyhydramnios OB Anemia/Parvo/Hydrops OB OB OB OB OB OB OB ------OB OB OB OB OB OB OB OB OB OB OB OB OB OB OB OB Monoamniotic Mu OB OB OB Fetal Anatomic Scan OB OB PPROM OB OB OB OB 18: Cervical Insufficiency/Current Preterm Labor Abnormalities/ Fluid Amniotic 17: Fetal of Causes Other Isoimmunization/ Alloimmunization/Rh 16: 15: Adnexal Mass/Uterine Fibroids and Uterine Anomalies 14: Abnormal Fetal Position/ Presentation 13: Fetal MRI 12: Fetal Echocardiography (ECHO) 11: Multiple Gestations 10: High Risk Medications andSubstances eviCore healthcare. All Rights Reserved. ------16.5: O 16.4: Other Fetal Hydrops/Nonimmune Hydrops 16.3: Twin Anemia Polycythemia Sequence 16.2: Exposure to Parvovirus B 16.1: Alloimmunization/Rh Isoimmunization 15.3: Uterine Anomalies in Pregnancy 15.2: Uterine Fibroids in Pregnancy Adnexal15.1: Mass 14.1: Abnormal Fetal Position or Presentation 13.1: Indications for Fetal MRI 12.4: Medication orDrug Exposure 12.3: Indications for Maternal Conditions 12.2: Indicat 12.1: Fetal Echocardiography 11.3: Known Monochorionic Known11.2:Dichorionic Multiple Gestations 11.1: Suspected Multiple Gestations 10.1: Medic of History 9.10: Stillbirth 9.9: History of Spontaneous Pre 9.8: Hypertensive Disorders in Pregnancy 9.7: High Risk Group Seven Gestational Diabetes 9.6: High Risk Group Six 18. 17.1: Amniotic Fluid Abnormalities 1: Cervical1: Insufficiency

ther Causes of Fetal Anemia Imaging

ations and Substances that Qualify for a Detailed ions for Fetal Conditions

ltiple Gestations Guidelines

–

Pre - Diamniotic or Monochorionic

– - -

Gestational Diabetes 19 - Coding Term Delivery/History of

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Obstetrical Ultrasound Imaging 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______Obstetrical Ultrasound ©2020 OB OB OB OB OB OB OB OB OB OB ------Anatomic Evaluation Ultrasound OB Ultrasound OB General Considerations OB OB OB OB OB OB (PPROM) OB OB OB OB OB Hematoma) OB OB OB OB OB OB OB OB OB OB 28: Procedure CodingBasics for Established Pregnancy 27: Unequal Fundal Size and Dates 26: Trauma Pregnancy of Termination 25: 24: Previous C 23: Preterm/Prelabor Rupture of Membranes 22: Late 21: Placental and Cord Abnormalities 20: Fetal Growth Problems (FGR and Macrosomia) 19: No Fetal Heart Tones/Decreased Fetal Movement eviCore healthcare. All Rights Reserved. ------28.2: Required Elements for Complete First Tr 28.1: Procedure Coding Basics for Established Pregnancy 27.1: Unequal Fundal Size and Dates 26.1: Trauma 25.1: Imaging for Planned Pregnancy Termination 2 23.2: Current Prelabor Rupture of Membranes (PROM) 23.1: Cur 22.1: Late 21.7: 21.6: Previa (Placenta Previa and Vasa Previa) 21.5: Suspected Abruptio Placentae 21.4: Subchorionic Hematoma/Hemorrhage (Placental 21.3: Placental/Cord Abnormalities 21. 21.1: Single Umbilical Artery (Two Vessel Cord) 20.2: Macrosomia 20.1: 19.2: Decreased Fetal Movement 1 18.3: Current Preterm Labor 18.2: Cerclage in Place in Current Pregnancy 28.3: Required Elements for Second orThird Trimester Fetal 4.1: Previous4.1: C 9.1: No Fetal Heart Tones 2: Persistent Right Umbilical Vein (PRUV)

- Placenta Accreta Spectrum (Accreta, Increta, Percreta) Fetal Growth Restriction Current Pregnancy

term/Post

Imaging

rent Preterm/Prelaborrent Rupture of Membranes - term/Post - section or History of Uterine Scar

– Guidelines

Imaging - - term Pregnancy section orHistory of Uterine Scar –

- Large for Dates Current Pregnancy term Pregnancy

–

Imaging

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imester

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Obstetrical Ultrasound Imaging 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______Obstetrical Ultrasound ©2020 OB OB OB OB OB OB OB OB Ultrasound OB eviCore healthcare. All Rights Reserved. ------28.12: 3D and 4D Rendering 28.11: Fetal Echocardiography Duplex28.10: Scan 28.9: Fetal Doppler 28.8: Biophysical Profile (BPP) 28.7: Obstetric Transvaginal Ultrasound 28.6: Limited and F 28.5: Fetal Nuchal Translucency 28.4: Required Elements for aDetailed Fetal Anatomic Evaluation

Imaging

Guidelines

ollow

- up Studies

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

Abbreviations and Glossary for OB Ultrasound Imaging Guidelines ACOG American College of Obstetricians and Gynecologists AFI amniotic fluid index AFP alpha-fetoprotein CST contraction stress test B-mode two dimensional imaging procedure, B-mode ultrasound is the basis for all (brightness) static and real time B-scan images Biophysical Profile includes the ultrasound variables: fetal breathing, muscle tone, and movement as well as amniotic fluid volume. BPP may be BPP performed with or without a non-stress test (NST) which involves fetal heart rate (FHR) monitoring. D & C/D & E dilatation and curettage/ Dilation and Evacuation twins having distinct chorions (membrane that forms the fetal part of the dichorionic placenta), including monozygotic twins (from one oocyte [egg]) separated twins within 72 hours of fertilization and all dizygotic twins (from two oocytes fertilized at the same time involves measuring a change in frequency when the motion of vascular flow Doppler is measured Estimated Date of Confinement; determined from the first day of the last EDC menstrual cycle EDD Estimated Date of Delivery FHR fetal heart rate hCG human chorionic gonadotropin IDDM insulin-dependent diabetes mellitus Fetal growth restriction; an estimated weight of the fetus at or below 10th FGR percentile for gestational age; and/or abdominal circumference of the fetus at or below 10th percentile for gestational age ultrasound imaging technique in which structure movement can be depicted M-mode in a wave-like manner; primarily used in cardiac and fetal cardiac imaging macrosomia estimated fetal weight of greater than 4000 or 4500 grams monochorionic twins developed from one oocyte (egg) developing with a single chorions twins (membrane that forms the fetal part of the placenta) NICU Neonatal Intensive Care Unit NST fetal non-stress test diminished amniotic fluid volume (AFV) for gestational age; definitions oligohydramnios include: maximum deepest pocket of ≤2cm and/or AFI of ≤5cm or

OB-1: Obstetrical Ultrasound Imaging General Guidelines OB-1.0: Obstetrical Imaging 8 OB-1.1: Required Documentation 8 OB-1.2: Inappropriate Use of OB Ultrasound 8 OB-1.3: Ultrasound Code Selection 8

______©2020 eviCore healthcare. All Rights Reserved. Page 7 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______ OB-1  tones) heart (fetal apregnancy of evidence clinical or test pregnancy apositive have not ultrasound Obstetrical OB-1   OB-1    OB-1 Obstetrical Ultrasound ©2020  See   is ultrasound Obstetrical    request: each with besubmitted must information The following requests imaging ultrasound obstetric to prior necessary is visit) initial office (an exam andphysical history with pregnancy of An evaluation    Imaging Pregnancy Risk) (Low Normal patients. all pregnant for isrecommended andit location, andplacental viability, number, fetal age, gestational determining of method anaccurate is assessment Ultrasound offersanin - This document

eviCore healthcare. All Rights Reserved. .3: .2: .1: .0 diagnosed. (CPT aneuploidy fetal for tools screening It is not appropriate to report non report to isnot appropriate It picture souvenir or akeepsake To provide only Sex determination available if studies ultrasound prior of Results service date of ageat Gestational delivery of date Expected ( N Fetal  mandated. beuniversally yet cannot PTB spontaneous a prior without gestations singleton in CL that screening state SMFMguidelines Current  Review. Director Medical to send gestation, weeks <16 If age. gestational of estimation women andanaccurate in most anatomy a fetal of survey for Thistiming allows 14weeks). after time any performed be may (but 22 gestation 18to of weeks isat examination ultrasound single a for time optimal the indications, specific other of absence the in ACOG, Per planned planned not is cfDNA) OB

: Obstetrical Imaging

Ultrasound Code Selection Code Ultrasound Ultrasound OB of Use Inappropriate Documentation Required poor poor transabdominal cervical length (CL) is ≤3.6 cm or in certain circumstances of pregnancy. Transvaginal ultrasound (CPT ultrasound Transvaginal CPT ultrasound anatomy afetal Report - ® 28: Procedure Coding Basics for Established Pregnancy Established for Basics Coding Procedure 28: 76830, CPT 76830, ucal ucal cervical

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Obstetrical Ultrasound Imaging 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______Obstetrical Ultrasound ©2020 CPT . reexamination requires than onearea when more anatomy CPT studies. transabdominal for used are codes CPT survey (CPT fetal astandard constraints, other or dueto geographic limited is access (CPT anatomy fetal adetailed where circumstances In imaging. in fetal training advanced with or a Radiologist (Perinatologist), aMaternal as such study, this perform skills to special those by with performed generally is evaluation anatomic fetal This detailed ultrasound. for indication medical isa new andthere anew at office caregiver anew medical to changes mother the unless pregnancy per once beused shouldonly These studies service. this includes study the onlywhen used andare survey anatomic anddetailed evaluation ultrasound CPT pregnancy risk) (low in anormal trimester, andthird second the during performed scan) (anatomy studies CPT disorders. genetic andother 18, Trisomy 21), (Trisomy Down for Syndrome assess risk to neck back fetal of the the at space of (translucent) the clear measurement anultrasound screening: translucency CPT isanew andthere new office a at caregiver anew medical to changes mother the unless pregnancy per once used (<14weeks). duringfirst trimester the performed studies CPT medical indication for indication medical isa new andthere anew at office caregiver anew medical to changes mother the  Itisalsousedtoreportamodified BPP.  CPT   ® ® ® ® ® ® ®

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medical indication for ultrasound. for indication medical (for each additional fetus) are reported for complete complete for are reported fetus) additional each (for CPT follow up follow

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Obstetrical Ultrasound Imaging 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______    Note Practice Obstetrical Ultrasound ©2020 CPT ultrasound. for indication isanewthere medical or anew office at caregiver changesanew medical to mother the unless pregnancy per once beused These shouldonly codes the echocardiogram. of portion Doppler profile MRI ( CPT abnor cord fetalumbilical report to used can It be andveins. arteries bloodin flow of anddirection pattern the characterizing CPT procedures. echocardiography CPT a CPT CPT CPT CPT follow up Doppler portion of the the of portion Doppler follow up . reimbursable separately isnot procedure, ultrasound astandard during identification, structure anatomical ( alone Doppler color of use The minimal recommended early of management clinical routine for use Doppler or uterine artery artery, cerebral middle ductus venosus, that suggest SMFM pregnancy) CPT CPT trimester) (CPT examination anatomic fetal detailed with ultrasound andmaternal fetal desirable the more perform can who a to provider access have not anddoes abnormality a fetal for risk have to anincreased isdeemed individual the where circumstances In ® ® ® ® ® ® ® ® eviCore healthcare. All Rights Reserved. indicated for more in depth imaging of certain fetalabnormalities certain of imaging inmore depth for indicated

9 76825 des 76825 artery. cerebral middle of the velocimetry Doppler describes 76821 umbilicalartery. of the velocimetry Doppler describes 76820 76818 74712 andCPT fetal with in conjunction mapping color beadded may for 93325 76826 (BPP), a test for antepartum fetal surveillance. fetal antepartum a for test (BPP), ® ® 3976 3976 ® 76805 (normal pregnancy) or Detailed anatomy scan CPT scan anatomy Detailed or pregnancy) (normal 76805 to aCPT prior beperformed not (should 76816

76811) due to geographic or other constraints, a standard (after first (after a standard constraints, other or dueto geographic 76811) malities) fetal and maternal ultrasound (CPT ultrasound fetal andmaternal (includes non- (includes describes a limited duplex scan and is used during pregnancy for for pregnancy during and isused scan duplex alimited describes follow up afollow describes cribes fetal echocardiography andCPT echocardiography fetal cribes (GRADE 2A) (GRADE Imaging . . ®

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Code Guidance Code

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Obstetrical Ultrasound Imaging 7. 8. 6. 5. 4. 3. 2. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______1. References Obstetrical Ultrasound ©2020 Martins JG, Biggio JR, Abuhamad A. Society for Maternal paper on Ultrasound Code 76811 Society for Maternal and Fetal Medicine (SMFM), coding committee, December 2012. SMFM’s white 192. doi:10.1097/01.aog.0000451759.90082.7b. Practice Bulletin No. 145: Gynecology. 2020. doi:10.1016/j.ajog.2020.05.010. #52: Diagnosis and Management of Fetal Growth Restriction. American Journal of Obstetrics and Medicine. 2019;39(1). doi:10.1002/jum.15188. AIUM Practice Parameter for the Performance of Fetal Echocardiography. Journal of Ultrasound in doi:10.1002/jum.14677. Advanced Clinical AIUM Practice Parameter for the Performance of Limited Obstetric Ultrasound Examinations by doi:10.1002/jum.15163. Obstetric Ultrasound Examinations. Journal of Ultrasound in Medicine. 2019;38(12):3093 AIUM Practice Parameter for the Performance of Detailed Second‐ doi:10.1002/jum.14831. Obstetric Ultrasound Examinations. Journal of Ultrasound in Medicine. 2018;37(11). AIUM Reaffirmed 2018. doi:10.1097/AOG.0000000000001815 . Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstet Gynecol. 2016;128(6):e241 Survey. 2014;69(8):453 and Society of Radiologists in Ultrasound Fetal Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, Maternal Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal Imaging: Executive Summary of a Joint eviCore healthcare. All Rights Reserved. - ACR - Fetal Medicine, American Institute of Ultrasound in Medicine, American College of - ACOG

- Providers. Journal of Ultrasound in Medicine. 2018;37(7):1587- Imaging SMFM - 455. doi:10.1097/01.ogx.0000453817.62105.4a.

- Antepartum Feta Antepartum SRU Practice Parameter for the Performance of Standard Diagnostic

Guidelines

l l Surveillance

Imaging Workshop. Obstetrical & Gynecological . Obstetrics & Gynecology. 2014;124(1):182 - Fetal Medicine (SMFM) Consult Series Fetal 8924 8924

and Third ‐

Trimester Diagnostic Trimester 1596. www.eviCore.com Page 11of109 - e256. - 3100. V3 .0 -

Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB-2: Uncertain Dates OB-2.1: Uncertain Dates/Unknown Last Menstrual Period (LMP) 13

______©2020 eviCore healthcare. All Rights Reserved. Page 12 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 4. 3. 2. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______1. References OB- Obstetrical Ultrasound ©2020   & Gynecology. 2017;129(3). ACOG Committee Opinion Number 688: Management of Suboptimally Dated Pregnancies, Obstetrics 2017;129(5):e150 ACOG Committee Opinion 700: No Methods for Estimating the Due Date. Obstetrics & Gynecology 2014;123(5):1070 and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Obstetrics & Gynecology. Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, Maternal Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal Imaging: Executive Summary of a Joint e256. Reaffirmed 2018. do Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstetrics & Gynecology. 2016;128(6):e241- of the uterus onabdominal uterus the of   dates confirm to be performed can one ultrasound year, past in the periods have beenirregular there or uncertain be≥ to thought When  dates: confirm to beperformed can oneultrasound year, past in the periods irregular been have there or isuncertain period menstrual last of the date the If 2.1: Uncertain Dates/Unknown Last Menstrual Period

eviCore healthcare. All Rights Reserved. there is a difference between the clin the isabetween difference there CPT or beenperformed yet CPT CPT performed fetus additional be<14 to weeks thought When - Fetal Medicine, American Institute

® ® ®

76815 76815 / 76805 76815 - - or e154. doi:10.1097/AOG.0000000000002046. 108 Imaging

and/or CPT and/or CPT CPT and/or 2. doi:10.1097/aog.0000000000000245. ) ) and/or CPT and/or ® i:10.1097/AOG.0000000000001815.

and and 14 weeks Guidelines

76811 if high risk if 76811 Reaffirmed 2019.

exam exam ® ®

76817 76817 :

76817 if a complete ultrasound has not yet been yet not has ultrasound acomplete if 76817 and - -

of Ultrasound in Medicine, American College of

there is a difference between the clinical size clinical the between is a difference there CPT

doi:10.1097/AOG.0000000000001949. the date of the last menstrual period is period menstrual last of the date the ical size of the uterus on uterus the of size ical

if if ® complete fetal anatomic scan has not has scan anatomic fetal complete

76801 76801 8924 8924 ( plus CPT plus ®

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(LMP) www.eviCore.com for each for Page 13of109

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB-3: Intrauterine Device (IUD) OB-3.1: Locate an Intrauterine Device (IUD) 15

OB -3.1: Locate an Intrauterine Device (IUD)  Can report CPT® 76801 and/or CPT® 76817 if <14 weeks and a complete ultrasound has not yet been performed or  CPT® 76815 and/or CPT® 76817 if complete ultrasound has already been performed  3-D Rendering (CPT® 76376/CPT® 76377) may be added for “Lost” IUD (inability to feel or see IUD string).

References 1. Nowitzki KM, Hoimes ML, Chen B, Zheng LZ, Kim YH. Ultrasonography of intrauterine devices. Ultrasonography. 2015;34(3):183-194. doi:10.14366/usg.15010. 2. ACOG Committee Opinion No 672 Clinical challenges of long-acting reversible contraceptive methods. Obstetrics & Gynecology. 2016;128(3):e69-e77. Reaffirmed 2019.doi:10.1097/aog.0000000000001644. 3. Verma U, Astudillo-Dávalos FE, Gerkowicz SA. Safe and cost-effective ultrasound guided removal of retained intrauterine device: our experience. Contraception. 2015;92(1):77-80. doi:10.1016/j.contraception.2015.02.008. 4. Prabhakaran S and Chuang A. In-office retrieval of intrauterine contraceptive devices with missing strings. Contraception. 2011;83(2):102-106. doi:10.1016/j.contraception.2010.07.004.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-4: Infertility OB-4.1: History of Infertility 17 OB-4.2: Present Pregnancy with ART Treatment (IVF) 17 OB-4.3: Recurrent Pregnancy Loss 17

OB -4.1: History of Infertility  If there is a history of infertility treatment (CPT® 76801 [plus CPT® 76802 for each additional fetus] and/or CPT® 76817 if <14 weeks, for dating) or  CPT® 76815 and/or CPT® 76817  Repeat ultrasound is not usually necessary unless there are new clinical indications

OB-4.2: Present Pregnancy with ART Treatment (IVF)  Follow high risk imaging, See OB-9: High Risk Pregnancy

OB-4.3: Recurrent Pregnancy Loss  Ultrasound imaging is supported if there is a history of at least 2 consecutive or 3 non-consecutive clinical miscarriages/losses at <20 weeks gestation (CPT® 76801 [plus CPT® 76802 for each additional fetus] and/or CPT® 76817 if <14 weeks, for dating) or  CPT® 76815 and/or CPT® 76817  Repeat ultrasound is not usually necessary unless there are new clinical indications. Send requests for repeat imaging to Medical Director Review References 1. Kondapalli LA, Perales-Puchalt A. Low birth weight: is it related to assisted reproductive technology or underlying infertility? Fertility and Sterility. 2013;99(2):303-310. doi:10.1016/j.fertnstert.2012.12.035. 2. Definitions of infertility and recurrent pregnancy loss: a committee opinion. Fertility and Sterility. 2020;113(3):533-535. doi:10.1016/j.fertnstert.2019.11.025. 3. ACOG Practice Bulletin No. 200. Early pregnancy loss. Obstetrics & Gynecology. 2018;132(5). doi:10.1097/aog.0000000000002899.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-5: Vaginal Bleeding and/or Abdominal/Pelvic Pain/Cramping OB-5.1: Abdominal/Pelvic Pain 19 OB-5.2: Vaginal Bleeding 19 OB-5.3: Ectopic Pregnancy 19 OB-5.4: Spontaneous Abortion/Threatened/Missed Abortion 20 OB-5.5: Hydatidiform Mole 20

______©2020 eviCore healthcare. All Rights Reserved. Page 18 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______OB- OB- OB-5 Obstetrical Ultrasound ©2020  First Trimester              pregnancy orwithnon beindicatedwithoutpainandbleeding, imaging mayalso painand/or Signs andsymptomsofectopicpregnancyinclude If vaginal bleeding with +KB (Kleihauer For suspected placental (See abruption, at26Additionally, starting BPP weeks, (CPT and CPT CPT CPT Limited < is CPT Ini CPT CPT CPT CPTInitially fetal anatomic scan CPT anatomic scan fetal (CPT anatomic scan fetal is < is previously beenperformed) fetal anemiafetal andhydrops CPT 5.3 5.2 eviCore healthcare. All Rights Reserved. .1: Abdominal .1: tially CPT 14 weeks 14 weeks or be required per be pregnancyIf ectopic is treatedbeing non-surgically with Methotrexate, imaging may Once confirmed, anadnexal is mass Color Doppler ultrasonography (CPT CPT or theimaging guidelines above pregnancy for ectopic toevaluatemay thevascular beuseful characteristics CPT d is < and is : EctopicPregnancy Bleeding Vaginal : ® ® ® ® ® ® ® Cord Cord

76816 CPT76805 (plus 76801 76816 CPT76805 (plus 76801 and/or CPT 93976 (limited duplexmay scan) anadd beindicated as -on, (See OB CPT ® ®

For abdominal For 76801 76815 and/or CPT ). Abnormalities 14 weeks ® ®

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Obstetrical Ultrasound Imaging 5. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______ACOG 4. 3. 2. 1. References OB- OB- Obstetrical Ultrasound ©2020   First, Second andThird Trimester   Network. 2019;17(11):1374- NCCN Clinical Practice Guidelines in Oncology. Journal of the National Comprehensive Cancer Abu Gynecology. 2016;128(5). doi:10.1097/aog.0000000000001768 . doi:10.1097/aog.0000000000002560. ACOG Practice Bulletin No. 193. Maternal for Society al. et J, Stone ME, Norton G, Mari doi:10.1097/aog.0000000000002899. ACOG Practice Bulletin No. 200. Early Pregnancy Loss. Gynecology. 2015;212(6):697- The fetus at risk for anemia weeks, or Earlyultrasoundcanbeperformed(CPT History ofaMolarPregnancy: agnosis ofhydatidiformmole Ultrasound canbeperformedfordi there For completespontaneousabortion,ultrasoundisgenerallynotindicatedif threatened orm Imaging maybeindicatedwithor 5.5 5.4 eviCore healthcare. All Rights Reserved. - Rustum NR, Yashar CM, Bean S, et al. Gestational Trophoblastic Neoplasia, Version 2.2019, s Ultrasound imagingcanberepeatedearlierthansevendays levels o CPT complete fetalanatomicscanCPT appropriate CPT performed, andis<14weeksor CPT See Ultrasound may for follow benecessary CPT CPT CPT CPT and is <14 and is weeks treatment, onset there or is if ofpain fallingdespite hCG titers. 76857) fetal anatomic scan CPT anatomic scan fetal : Hydatidiform Abortion Spontaneous : y Practice Bulletin No. 174. Evaluation and Management of Adnexal Masses. mptoms is no ® ® ® : PV-16.1 ® ® ® ®

CPT 76805 (plus CPT76805 (plus 76801

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB-6: Fetal Aneuploidy and Anomaly Screening OB-6.1: First Trimester Screening 22 OB-6.2: Second Trimester Screening 23

______©2020 eviCore healthcare. All Rights Reserved. Page 21 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______  Notes Coding       OB-6 Obstetrical Ultrasound ©2020    along with the nuchal translucency screening (CPT screening nuchaltranslucency the along with CPT the then indication, fetal and/or (CPT nuchaltranslucency for anultrasound whenever beroutinelydone NOT and should (CPT codes ultrasound of The use (NTQR) Program Review Quality Translucency Nuchal or Foundation Medicine Fetal the by certified those only by performed CPT positive. if as managed should patients These of aneuploidy. risk ahigher has which also result indeterminate or call” A “no One Group Risk ( scan anatomy a detailed CVS) and Those fetal aneuploidy for tools screening both they as are been performed, NT Fetal accurate). (99% andGenomics Genetics Medical of College thecurrently sensitive most scre - Cell 83 weeks when performed accurate most is translucency Nuchal fetuses in euploid syndromes genetic or defects structural or other cardiac defects for risk anincreased alsoindicate may aneuploidy with afetus may indicate mm), (CPT (NT) First trimester CPT should or amniocentesis) beevaluated (CPT echo with afetal CVS cfDNA, A If for the Ultrasound n a eviCore healthcare. All Rights Reserved. increased increased NuchalFetal Translucency (NTmm) ≥3.0 .1: First Trimester Screening mm regardless of gestational age gestational of regardless mm cfDNA, cfDNA, anatomicFetal ultrasound (CPT ® Free DNA (cfDNA) can be performed any time after 10 weeks gestation andis aftergestation any10weeks time beperformed can DNA (cfDNA) Free ® ® bnormal bnormal / 76813

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB -6.2: Second Trimester Screening Second Trimester Screening:  A fetal anatomy ultrasound (CPT® 76805) and/or QUAD screen can be performed during the second trimester to detect fetal aneuploidy, neural tube defects, and other anatomical defects. See OB-7.1: Fetal Anatomic Scan  If the quad screening is abnormal, a detailed anatomy ultrasound (CPT® 76811) may also be performed. Practice Notes Multiple marker screening is used in the second trimester (15 to 20 weeks) to screen for aneuploidy as well as open neural tube defects (ONTD).  Maternal serum alpha-fetoprotein (MSAFP) can be done at 15 to 20 weeks to screen for neural tube defects in those that have had cfDNA or NT screen.  The “quad” screen (AFP (alpha-fetoprotein), hCG (human chorionic gonadotropin), uE (Unconjugated estriol), dimeric inhibin-A) is the most commonly used test for the second trimester.  A penta screen (quad screen markers + hyperglycosylated hCG) may be done in lieu of a quad screen.  Combined, integrated or sequential screening (first and second trimester screening) may also be used and provides a higher detection rate than a single screening.  Providers often wait for the results of the quad screen before ordering CPT® 76805. If the quad screen is abnormal, they may request CPT® 76811 in lieu of CPT® 76805.

References 1. ACOG Practice Bulletin No. 163: Screening for Fetal Aneuploidy. Obstet Gynecol. 2016;127(5):e123-

e137. Reaffirmed 2018. doi:10.1097/AOG.0000000000001406. 2. ACOG Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstet Gynecol. 2016;128(6):e241-e256. Reaffirmed 2018. doi:10.1097/AOG.0000000000001815. 3. Gregg AR, Skotko BG, Benkendorf JL, et al. Noninvasive prenatal screening for fetal aneuploidy, 2016 update: a position statement of the American College of Medical Genetics and Genomics. Genetics in Medicine. 2016;18(10):1056-1065. doi:10.1038/gim.2016.97. 4. Norton ME, Biggio JR, Kuller JA, Blackwell SC. Society for Maternal-Fetal Medicine (SMFM) Consult Series | #42: The role of ultrasound in women who undergo cell-free DNA screening. American Journal of Obstetrics and Gynecology. 2017;216(3):B2-B7. doi:10.1016/j.ajog.2017.01.005. 5. Society for Maternal and Fetal Medicine (SMFM), coding committee, October 2017. SMFM’s white paper on billing combination of 76801 and 76813 6. ACOG Practice Bulletin No. 162 Prenatal diagnostic testing for genetic disorders. Obstetrics & Gynecology. 2016;127(5). Reaffirmed 2018. doi:10.1097/aog.0000000000001405. 7. Donofrio MT, Moon-Grady AJ, Hornberger LK, et al. Diagnosis and Treatment of Fetal Cardiac Disease. Circulation. 2014;129(21):2183-2242. doi:10.1161/01.cir.0000437597.44550.5d. 8. ACOG Practice Bulletin: No.187: Neural Tube Defects. Obstet Gynceol. 2017 Dec;130(6):e279-e290. doi: 10.1097/AOG.0000000000002412.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-7: Fetal Anatomic Scan OB-7.1: Fetal Anatomic Scan 25 OB-7.2: Fetal Anatomic Scan – Follow-up 25

OB -7.1: Fetal Anatomic Scan  Per ACOG, in the absence of other specific indications, the optimal time for a single ultrasound examination is at 18 to 22 weeks of gestation (but may be performed any time after 14 weeks). This timing allows for a survey of fetal anatomy in most women and an accurate estimation of gestational age. If <16 weeks gestation, send to Medical Director Review.  Report a fetal anatomy ultrasound CPT® 76805 for a normal/low risk pregnancy.  If pregnancy is high risk report a detailed fetal anatomy ultrasound (CPT® 76811). This is generally performed by a Maternal Fetal Medicine (MFM)/Perinatologist, or a Radiologist at an AIUM or ACR accredited facility. See OB-9: High Risk Pregnancy  Current SMFM guidelines state that CL screening in singleton gestations without a prior spontaneous PTB cannot yet be universally mandated.  Transvaginal ultrasound (CPT® 76817) may be considered if the transabdominal cervical length (CL) is ≤3.6 cm or in certain circumstances of poor cervical visualization on transabdominal ultrasound 

OB-7.2: Fetal Anatomic Scan – Follow-up  Follow-up ultrasounds (CPT® 76815 to assess a single item or CPT® 76816 if multiple areas to be assessed) can be performed once for incomplete or equivocal finding on initial fetal anatomic scan.  CPT® 76816 (should not be performed prior to a CPT® 76801 or an anatomy scan CPT® 76805 (normal pregnancy) or Detailed anatomy scan CPT® 76811 (high risk pregnancy)  If pregnancy is high risk See OB-9: High Risk Pregnancy or other applicable high risk guideline.

 Detailed anatomy ultrasound CPT® 76811 can be performed if not previously performed when initial fetal anatomic scan CPT® 76805 is abnormal. See OB-9: High Risk Pregnancy

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

References 1. AIUM-ACR-ACOG-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound Examinations. Journal of Ultrasound in Medicine. 2018;37(11). doi:10.1002/jum.14831. 2. AIUM Practice Parameter for the Performance of Detailed Second‐ and Third‐Trimester Diagnostic Obstetric Ultrasound Examinations. Journal of Ultrasound in Medicine. 2019;38(12):3093-3100. doi:10.1002/jum.15163. 3. Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstet Gynecol. 2016;128(6):e241- e256.Reaffirmed 2018. doi:10.1097/AOG.0000000000001815. 4. AIUM Practice Parameter for the Performance of Limited Obstetric Ultrasound Examinations by Advanced Clinical Providers. Journal of Ultrasound in Medicine. 2018;37(7):1587-1596. doi:10.1002/jum.14677. 5. American Medical Association. CPT—Current Procedural Terminology. American Medical Association. https://www.ama-assn.org/practice-management/cpt. Published 2019. Copyright 1995 - 2019. 6. ACOG Practice Bulletin No.130: Prediction and Prevention of Preterm Birth. Obstet Gynecol. 2012;120(4):964-973. Reaffirmed 2016. doi:10.1097/AOG.0b013e3182723b1b. 7. Cho HJ, Roh H-J. Correlation Between Cervical Lengths Measured by Transabdominal and Transvaginal Sonography for Predicting Preterm Birth. Journal of Ultrasound in Medicine. 2016;35(3):537-544. doi:10.7863/ultra.15.03026. 8. Esplin MS, Elovitz MA, Iams JD, et al. Predictive Accuracy of Serial Transvaginal Cervical Lengths and Quantitative Vaginal Fetal Fibronectin Levels for Spontaneous Preterm Birth Among Nulliparous Women. JAMA. 2017;317(10):1047. doi:10.1001/jama.2017.1373. 9. Jain S, Kilgore M, Edwards RK, Owen J. Revisiting the cost-effectiveness of universal cervical length screening: importance of progesterone efficacy. American Journal of Obstetrics and Gynecology. 2016;215(1). doi:10.1016/j.ajog.2016.01.165 10. Blackwell SC, Gyamfi-Bannerman C, Biggio JR Jr, et al. 17-OHPC to Prevent Recurrent Preterm Birth in Singleton Gestations (PROLONG Study): A Multicenter, International, Randomized Double- Blind Trial. Am J Perinatol. 2020;37(2):127–136. doi:10.1055/s-0039-3400227. 11. Mcintosh J, Feltovich H, Berghella V, Manuck T. The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. Society for Maternal-Fetal Medicine (SMFM) Consult Series #40. American Journal of Obstetrics and Gynecology. 2016;215(3). doi:10.1016/j.ajog.2016.04.027. 12. Friedman AM, Schwartz N, Ludmir J, Parry S, Bastek JA, Sehdev HM. Can transabdominal

ultrasound identify women at high risk for short cervical length? Acta Obstetricia et Gynecologica Scandinavica. 2013;92(6):637-641. doi:10.1111/aogs.12111 Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-8: Third Trimester Imaging OB-8.1: Third Trimester Imaging – Ultrasound 28

______©2020 eviCore healthcare. All Rights Reserved. Page 27 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______1. Reference OB-8 Obstetrical Ultrasound ©2020   Reaffirmed 2018. doi:10.1097/AOG.0000000000001815. Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstet Gynecol. 2016;128(6):e241 / Position S position, breech suspected For  high other - and/or movement fetal decreased s, tone heart fetal absent pain, isindicatedbleeding, for trimester third in the Imaging

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB-9: High Risk Pregnancy OB-9.0: High Risk General Information 30 OB-9.1: High Risk Group One – Risk Factors 30 OB-9.2: High Risk Group Two – Findings on Ultrasound that May Require Further Imaging 33 OB-9.2.1: Soft Markers for Aneuploidy 33 OB-9.2.2: Other Findings on Ultrasound that May Require Further Imaging 33 OB-9.3: High Risk Group Three – High BMI (>30 kg/m2) 34 OB-9.3.1: Class I Obesity - Pre-pregnancy BMI 30 to 34.9 34 OB-9.3.2: Class II Obesity - Pre-pregnancy BMI 35-39.9 34 OB-9.3.3: Class III Obesity - Pre-pregnancy BMI ≥40 34 OB-9.4: High Risk Group Four – Macrosomia 35 OB-9.4.1: Prior Pregnancy with Macrosomia 35 OB-9.4.2: Current Pregnancy with Suspected or Known Macrosomia 35 OB-9.5: High Risk Group Five – Zika and COVID-19 Virus 35 OB-9.5.1: Zika Virus 35 OB-9.5.2: COVID-19 Virus 36 OB-9.6: High Risk Group Six – Pre-Gestational Diabetes 37 OB-9.6.1: Pre-Gestational or Early Diagnosed Diabetes - not on Medication 37 OB-9.6.2: Pre-Gestational or Early Diagnosed Diabetes - on Medication 37 OB-9.7: High Risk Group Seven Gestational Diabetes 38 OB-9.7.1: Gestational Diabetes - Diet-Controlled (GDM-A1) 38 OB-9.7.2: Gestational Diabetes (GDM-A2) on Medications 38 OB-9.8: Hypertensive Disorders in Pregnancy 39 OB-9.8.1: Screening in High Risk Groups 39 OB-9.8.2: Current Chronic Hypertension not on Medication 39 OB-9.8.3: Current Chronic Hypertension on Medication 39 OB-9.8.4: Gestational Hypertension (GH, preeclampsia, toxemia) 40 OB-9.9: History of Spontaneous Pre-Term Delivery/History of PPROM 41 OB-9.9.1: Spontaneous Preterm Delivery ≤34 Weeks; History of PPROM ≤34 weeks 41 OB-9.9.2: History of Spontaneous Preterm Delivery >34 weeks <37 weeks; History of PPROM >34 weeks <37 weeks 41 OB-9.10: History of Stillbirth 42

______©2020 eviCore healthcare. All Rights Reserved. Page 29 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com   400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______restriction growth for concerning findings other of absence the in beindicated not may ultrasounds growth serial growth, abnormal detected antenatally for evidence limited given the however, Scan), Anatomic Fetal Detailed a OB (See beindicated 76811 may least (at trimesters andsecond first the during particularly marijuana, who more used women pronounced among more were findings These marijuana. to exposed among offspring weights birth lower noted studies Several Notes Practice OB-9     Risk High OB-9.0 Obstetrical Ultrasound ©2020      Factors Risk Related Lifestyle  Socio (CPT desi the more perform can who a to provider access have not anddoes abnormality afetal for risk have to anincreased isdeemed individual the where circumstances In imaging. in fetal training advanced with or a Radiologist (Perinatologist), aMaternal as such study, this perform skills to special those by with performed generally is evaluation anatomic fetal This detailed is when criteria is recommended early of management clinical routine for use Doppler or uterineartery artery, cerebral middle ductusvenosus, that suggest SMFM pregnancy) CPT CPT in change condition. and/or indication isanew medical andthere office anew at caregiver anew medical to changes mother the unless pregnancy per CPT (CPT ultrasound fetalandmaternal trimester) A Current ofSuboxone, use Maternal abuse history ofIV drug Othe ≥ Medications andSubstances that Qualifya Detailed Fetal Anatomic Scan for drug orRecreational alcoholduring use pregnancy current Age Detailed Fetal Anatomic Scan ( Scan Anatomic Fetal Detailed 10 cigarettes aday 10 cigarettes can can but between20weeks, 18to performed ideally eviCore healthcare. All Rights Reserved. .1: High Risk Group One Group Risk High .1: - rable fetal and maternal ultrasound with detailed fetal anatomic examination anatomic fetal detailed with ultrasound andmaternal fetal rable ® ® ® Demographic Risk Factors (maternal age) (maternal Factors Risk Demographic : High Risk General Information General Risk High : ® ≥ r nicotine exposure (e 76805 (normal pregnancy) or Detailed anatomy scan CPT scan anatomy Detailed or pregnancy) (normal 76805 to aCPT prior beperformed not (should 76816 , 76805

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

Maternal Infections (not exposure)  Acquired Immune Deficiency Syndrome/HIV Positive  Chicken Pox/Varicella  Cytomegalovirus (CMV)  Malaria  Known parvovirus in current pregnancy post fetal treatment. See OB-16.2: Exposure to Parvovirus B-19  Rubella  Syphilis, untreated  Toxoplasmosis  Tuberculosis  For Zika Virus and COVID-19 Virus See OB-9.5: High Risk Group Five: Zika and COVID-19 Virus

Imaging For Above Conditions  CPT® 76801 [plus CPT® 76802 for each additional fetus] if <14 weeks and a complete ultrasound has not yet been performed, and/or  CPT® 76817 for a transvaginal ultrasound or  CPT® 76815 can be performed for dating or quick look follow-up if ≥14 weeks but <16 weeks  Detailed Fetal Anatomic Scan CPT® 76811 ≥16 weeks when criteria is met  Starting at 23 follow-up growth scans (CPT® 76816) every 3 to 6 weeks  Starting at 32 weeks, weekly BPP (CPT® 76818 or CPT® 76819) or modified BPP (CPT® 76815)

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

______©2020 eviCore healthcare. All Rights Reserved. Page 32 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______OB- OB- Imaging Further Require OB-9 Obstetrical Ultrasound ©2020      Detailed f Detailed imaging: pregnancyon of current in fetus found are conditions following the If 9.2.2: 9.2.1: One follow One Fetal Detailed imaging: following the If eviCore healthcare. All Rights Reserved. .2: High Risk Group Two Two Group Risk High .2: Current pregnancy with suspected fetal anomaly on routine anatomic survey anatomic onroutine anomaly fetal suspected pregnancywith Current str and/or achromosomal with pregnancy Prior - intra Echogenic cyst plexus Choroid ) ) warranted Imaging See nasalbone Hypoplastic bowel Echogenic One Group ( 20weeks at Shortened Other Findings on Ultrasound that May Requir Soft Markers for Aneuploidy OB etal - up scan ( up scan - 9.2.2: Other Findings on Ultrasound that May that Ultrasound on Findings Other 9.2.2: - intra Echogenic Fetal for

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long bones ( bones long anatomic scan ≥ scan anatomic Imaging ‘softroutine on pregnancy markers’ current of found in are fetus - - For For ) ) factors Risk cardiac foci ( foci cardiac CPT as as defined Hydronephrosis

Guidelines ®

76816) femur femur 16 weeks (CPT 16 weeks

16 weeks (CPT 16 weeks Fetal echo or follow Fetal or echo – – and/or humerus) identified Pyelectasis of ≥ of Pyelectasis identified humerus) and/or

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Obstetrical Ultrasound Imaging 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______OB- OB- OB- OB- Obstetrical Ultrasound ©2020        After first andAfter trimester first outlined as second imaging above andAfter trimester first outlined as second imaging above (CPT andAfter trimester first outlined as second imaging above, Report f Detailed yet been performed not has ultrasound complete CPT CPT and/or yet been performed, not has ultrasound complete CPT 9.3.3: 9.3.2: 9.3.1: 9.3: eviCore healthcare. All Rights Reserved. BPP (CPT (CPT Growths scan BPP (CPT (CPT Growths scan to If unable height fundal clinically assess dueto body growth scan habitus (CPT 76816) can 76816) can be considered theearly in with follow trimester third 4weeks upin 32 weeks 36 weeks ® ® ® ®

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Obstetrical Ultrasound Imaging 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______OB- OB-9   OB- OB- OB-9 Obstetrical Ultrasound ©2020    known or symptoms with exposure Suspected    symptoms without exposure Suspected    90 the than greater termor at grams >4000 weighing (baby macrosomia with pregnancy Prior See See 9.5.1: Zika Virus 9.4.2: Current Pregnancy with Suspected or Known Macrosomia 9.4.1: Prior Pregnancy with Macro Current Pregnancy Current If FGR diagnosed CPT scan anatomic Fetal R developed, symptoms if positive or test If CPT scan anatomic Fetal R  One growth scan (CPTOnescan growth fetalA detailed anatomy  Report oneofthefollowing  eviCore healthcare. All Rights Reserved. eport one of following of the one eport following: of the one eport .5: High Risk Group Five Group Risk High .5: Four Group Risk High .4:

complete ultrasound has not yet been performed, and/or yet been performed, not has ultrasound complete CPT not CPT CPT and/or yet been performed, not has ultrasound complete CPT not CPT CPT OB OB CPT hasultrasound notyet beenperformed, and/or CPT CPT already beenperformed, and

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76815 ( 76815 CPT [plus 76801 ( 76815 CPT [plus 76801 76817 for a transvaginal ultrasound or ultrasound a transvaginal for 76817 76817 for a transvaginal ultrasound or ultrasound a transvaginal for 76817 76815 CPT76801 [plus 76817 for atransvaginal ultrasound or Imaging (limited limited limited th then follow FGR imaging imaging FGR follow then

percentile of expected weight) expected of percentile

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scan (CPT scan ultrasound) ultrasound) ® a ® ®

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regnancy Virus

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www.eviCore.com Page 35of109

V3 .0

Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB -9.5.2: COVID-19 Virus

Person Under Investigation (PUI) for infection or known infection  Report one of the following: CPT® 76801 [plus CPT® 76802 for each additional fetus] if <14 weeks and a complete ultrasound has not yet been performed, and/or CPT® 76817 for a transvaginal ultrasound or CPT® 76815 (limited ultrasound) can be performed for dating if an ultrasound not already been performed and ≥14 week and <16 weeks  Fetal anatomic scan CPT® 76805 or CPT® 76811 at ≥16 weeks.  Growth scan (CPT® 76816) every 3 to 4 weeks starting at 23 weeks (See OB-9.1: High Risk Group One - Risk factors).  If FGR diagnosed then follow FGR imaging OB-20.1: Fetal Growth Restriction Current Pregnancy  BPP or other imaging requests – send to Medical Director Review Practice Notes SMFM recommendation during COVID pandemic:  Combine dating/NT to one ultrasound based on LMP. If ultrasound earlier in the first trimester (e.g., <10 weeks) is indicated due to threatened abortion, pregnancy of unknown anatomic location, may consider foregoing NT ultrasound and offering cell free DNA screening for those desiring early aneuploidy screening  Perform Anatomy Ultrasound at 20-22 weeks and if needed, consider follow up views in 4-8 weeks rather than 1-2 weeks.  If serial cervical length assessments are indicated, consider stopping after anatomy u/s if transvaginal cervical length ≥35 mm, or if prior preterm birth at >34 weeks  BMI >40: schedule anatomy at 22 weeks to reduce risk of suboptimal views/need for

follow up  If Growth Ultrasounds indicated – recommend a single third trimester growth at 32 weeks.  Follow up previa/low lying placenta at 34-36 weeks

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

______©2020 eviCore healthcare. All Rights Reserved. Page 36 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______ Notes Practice OB- OB- OB-9 Obstetrical Ultrasound ©2020 Review to forRequests follow (initial) echo Fetal anatomicFetal scan (if (if arteryUmbilical Doppler or AFI with NST* (BPP) Profile Biophysical growth) (forUltrasound fetal weeks and dating prior no Dating if Ultrasound Ultrasounds TrimesterFirst (BPP) or modified BPP modified (BPP) or Profile Biophysical growth (forUltrasound feta R go toM forRequests follow (initial) echo Fetal anatomicFetal scan weeks and dating prior no Dating if Ultrasound Ultrasounds TrimesterFirst eview Medical Director Medical FGR FGR (HbA A ahemoglobin of criteria diagnostic standard the with trimester second early ACOG Per diabetes ona75 - mg/dL 9.6.2: 9.6.1: eviCore healthcare. All Rights Reserved. .6: High Risk Group Group Risk High .6:

)

edical edical diagnosed) 1C ) Test Test

≥ Pre Pre

6.5%, a fasting plasma glucose ≥ glucose plasma afasting 6.5%, D

- I - - - irector ≥ ≥ Gestational Gestational

f diabetes is diagnosed prior to pregnancy or in or the to pregnancy prior first isdiagnosed diabetes f trimester or 14

-up go - pre it isconsidered test, tolerance glucose g oral -up l

Imaging

Starting at≥ risk factorsrisk complicated at≥26start i weeks (mayStarting at32weeks weeks Starting atviability 23 14 ≥ <14 weeks ≥ of Upon diagnosis Starting at32weeks trimester S Starting at≥1 6 ≥ 14-16 weeks <14 weeks 23 weeks 23 16 weeks

16 weeks Guidelines tarting tarting -16 weeks or Early Dia or Early Diagnosed

Six in in When

When

)

the 3

– – 16 weeks 16 by by

Pre additional

weeks rd

FGR if f - Gestational Diabetes gnosed

126 mg/dL, a2- or mg/dL, 126 Onc Once Once Once weekly Up totwice weeks Every 2to4 Weekly Frequency Once week Once per weeks weeks Every 3to6 Once Once Once

Frequency 8924 8924 Diabetes Diabetes - e

76815 (m 76819 (BPP)o CPT CP CPT CPT CPT CPT CPT CPT CPT CPT

hour glucose of ≥ hour of glucose -

T on Medication not on CPT CPT CPT CPT CPT CPT CPT CPT BPP CPT CPT CPT ® ® ® ® ® ® ® ® ® ® 76818 (BPP)o

gestational 76820 76816 93325 76827 76825 76811 76817 76801 and/or 76815

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Codes 76819 (BPP) or (BPP)or 76819 76818 76816 93325 76827 76825 76811 76817 76801 and/or

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Obstetrical Ultrasound Imaging 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______OB- OB- OB-9 Obstetrical Ultrasound ©2020 diagnosed) Doppler FGR (if arteryUmbilical BPP modified (BPP) or Profile Biophysical growth) (forUltrasound fetal Director Review up gotoMedical forRequests follow (initial) echo Fetal anatomicFetal scan modified BPP (BPP)or Profile l Biophysica growth)fetal (forUltrasound scan anatomicFetal 9.7.2: Gesta tional Diabetes 9.7.1: Gestational

patient Test

If patient

has gestational diabetes and is on oral medication orinsulin: medication oral on is and diabetes hasgestational

- at 32weeks diagnosis, then starting Once a ≥ Starting at34weeks Imaging

16 weeks ≥ ofFGR Upon if diagnosis risk factors) complicated ( Starting at32weeks weeks Starting atviability 23 ≥ ≥

has gestational diabetes and it is diet controlled: diet is it and diabetes hasgestational may at≥26 start if 23 weeks weeks 16 16 weeks Diabetes t thetime of

Guidelines When

When

by by

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Gestational Diabetes

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8924 8924

(GDM

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CPT CPT CPT BPP) CPT CPT CPT CPT CPT CPT CPT CPT BPP CPT CPT CPT ® ® ® ® ® ® ® ® ® ) ® ® ® ® ®

76811 76820 76815 76819 76818 76816 93325 76827 76825 76815 76819 76818 76816 76805 www.eviCore.com Codes Codes Page 38of109

(BPP) (modified (BPP) or and/or and/or (BPP) (modified (BPP) or

Obstetrical Ultrasound Imaging 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______OB- OB- OB- OB-9 Obstetrical Ultrasound ©2020 (GH, p Pr Restriction Current See FGR diagnosed) arteryUmbilical (if Doppler modified BPP Biophysical (BPP)profile or (forUltrasound growth) fetal Scan FetalDetailed Anatomic da no Dating if Ultrasound prior TrimesterFirst Ultrasounds frombaseline,Se If bloodpressureiselevated (forUltrasound growth) fetal anatomicFetal scan and dating no Dating if Ultrasound prior TrimesterFirst Ultrasounds  egnancy ting and ting use forscreeninginhighriskgroupsisnotrecommended(GRADE2A) c S 9.8.3: Current Chronic Hypertension on Medication 9.8.2: 9.8.1: OB Assuch,its mortality. utilityinpredictingFGR,SGAbirth,andperinatal linical M eviCore healthcare. All Rights Reserved. .8: Hypertensi reeclampsia, toxemia)below FM statethat .1: Fetal Growth Fetal Growth -20.1: ≥ ≥ Current Chronic Hypertension not on Medication Screening

Test Test 14 weeks 14 weeks

Imaging

and uterine arteryDopplerhaslimiteddiagnosticaccuracy ve Disorders in Pregnancy in Disorders ve in High Risk Groups

< < Guidelines 14-16 weeks (>28 trimesterIn thethird ≥16 weeks FGR if if FGR of Upon diagnosis weeks may≥ at start risk factorsadditional (If complicated by Starting at32w gestationweeks Starting ≥ 14-16 weeks 14 weeks 16 weeks 16 weeks 14 weeks weeks

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-6

CPT CPT CPT CPT CPT

H CPT CPT CPT CPT CPT CPT CPT CPT CPT ® ® ® ® ® ypertension

76816 76811 76815 76817 76801 and/ ® ® ® ® ® ® ® ® ®

76820 76815 76819 76818 76816 76811 76815 76817 76801 and/or Codes www.eviCore.com Codes

Page 39of109

(AFI) (BPP) or (BPP) or

or or

Obstetrical Ultrasound Imaging 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______Practice OB- Obstetrical Ultrasound ©2020 Eclampsia Preeclampsia hypertension Gestational preclampsia with superimposed hypertensionChronic hypertensionChronic hypertension range Severe- pregnancy Hypertension in Pregnancy Current Restriction Growth OB Doppler arteryUmbilical modified BPP BPP or Growth US scan anatomicFetal 20.1: Fetal -20.1: Fetal 9.8.4: Gestational Hypertension

Oligohydramnios diagnosis of FGR or Starting attime ≥16 weeks diagnosis diagnosis Starting attime Starting attime Imaging

is among is themore manifestations severe Convulsivemanifestation ofthehypertensive disorders ofpregnancy and the absence ofproteinuria. ofpreeclampsiaother signs or some may symptoms in in present women Although often by accompanied new mostoccurs oftenafter of20 weeks and gestation frequently near term. Disorder ofpregnancy with new associated previously normal pressure. blood Hypertension ofgestation, awoman in diagnosed after 20weeks with a ofgestationor before 20weeks awomanPreclampsia in with ahistory before ofhypertension pregnancy pregnancy andthatdoes of gestation; or hypertension thatis fordiagnosed time thefirst during Hypertension diagnosed or present before pregnancy or before 20weeks both, measured atleast ontwo occasions 4hours apart bloodSystolic pressure ≥160 or diastolic mm Hg BP ≥11 measured on two occasions at least measured atleast ontwo apart occasions 4 hours bloodSystolic pressure ≥140 or diastolic mm Hg BP ≥90 mm Hg, or both, When

Guidelines

of of of

is also pre also is If FGR or Oligohydramnios Once weekly 2 to4weeks) severe (every preeclampsia orIf FGR, Oligohydramnios Every 3to4weeks Once Twice weekly Twice

(GH, preeclampsia, toxemia) not resolve the in

Frequency sent, weekly twice Definition

8924 8924 onset proteinuria,-onset hypertension and

of the disease. of

onset hypertension, which -onset postpartum period

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Page 40of109

Obstetrical Ultrasound Imaging 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______  History of PPROM >34 weeks <37 weeks OB-      weeks OB- OB- Obstetrical Ultrasound  ©2020   weeks CPT pregnancy. this during yet been performed not has scan anatomic fetal and/or fetus] additional each 76812 for CPT ultrasound An anatomy See OB labor preterm current For    pregnancy a singleton in ultrasound transvaginal a on found cm) is (2.5 mm cervix ≤25 short or funneling If CPT CPT BBP weekly at 32 weeks, Starting ev performed ≥ at scan anatomic fetal the after Starting weeks 76812 Ultrasound Anatomy Fetal CPT pregnancy. this during yet beenperformed not has 9.9.2: History o 9.9.1: Spontaneous For initial imaging For For initial imaging For 9.9

eviCore healthcare. All Rights Reserved. and/or Note: CPT Note: CPT CPT not CPT CPT not has ultrasound complete CPT ® ® ® already been performed and performed been already CPT CPT and/or yet been performed, not has ultrasound complete CPT : History of

76815 CPT and/or 76817 76815 and/or CPT and/or 76815 for each additional each for

® ® already been performed and beenperformed already ® ® ® ® ® ® 76817 and/or CPT and/or 76817 4weeks 3to every ultrasound acomplete after beperformed may 76816

76815 ( 76815 CPT [plus 76801 7 CPT [plus 76801 76817 for a transvaginal ultrasound or ultrasound a transvaginal for 76817 76817 for a transvaginal ultrasound or ultrasound a transvaginal for 76817 6815 ( 6815 ery 3 to 6 weeks until delivery 3to until 6 weeks ery ® 76815 should not be done on same date of service as CPT service of date doneonsame be not 76815 should Imaging limited limited f : : Spontaneous Spontaneous Spontaneous

Guidelines Preterm Delivery ≤34 Weeks; HistoryPreterm Weeks; Delivery of ≤34 PPROM ≤34 ® ®

ultrasound)

fetus] if 76817 every 2 weeks, starting at ≥ at starting 2weeks, every 76817 ≥ at starting 2weeks, every 76815 CPT ® ® ® ® 76802 for each additional fetus] if anda if weeks <14 fetus] additional each for 76802 76802 for each additional fetus] if anda if weeks <14 fetus] additional each for 76802 76815 every 1 to 2 weeks until 32weeks 1to until 2 weeks every 76815

76805 or CPT or 76805 ®

76805 or CPT 76805 or yet been performed, performed, been yet ≥ - ≥ : Current Preterm Labor Preterm Current : 18.3 14 weekand 16 weeks and a complete fetal anatomic scan anatomic fetal andacomplete 16 weeks Preterm Delivery >34 weeks <

Pre ≥ can be performed for dating if an ultrasound anultrasound if dating for can beperformed can be performed for dating if an ultrasound not anultrasound if dating for can beperformed 14 weekand ®

CPT

76818 or CPT or 76818 23 weeks, ultrasound (CPT 23 ultrasound weeks, - Term Delivery/Historyof PPROM

® ® 76811 [pl 76817 if >16 weeks and acomplete and weeks >16 76817 if ®

<16 weeks weeks <16 76811 [plus [plus 76811

8924 8924

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76819 or modified BPP modified 76819 or

16 weeks 24 until 16 weeks 24 until CPT

76810 or CPT or 76810 ®

76810 or CPT 76810 or ® www.eviCore.com

76816) can be can 76816) 37 Page 41of109 weeks; weeks; ® 76816 ® V3 ® .0

Obstetrical Ultrasound Imaging 7. 6. 5. 4. 3. 2.  400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______1. References  Notes Practice    OB-   Obstetrical Ultrasound ©2020  Disease. Circulation. 2014;129(21):2183 DonofrioMT, Moon Gynecology.2016;215(3). doi:10.1016/j.ajog.2016.04.027. selected high Mcintosh J, Feltovich H, Berghella V, Manuck T. The role of routine cervical length screening in doi:10.1097/AOG.0000000000002899. ACOG Practice Bulletin No. 200: Early Pregnancy Loss. Obstet Gynecol. 2018;132(5):e197 doi:10.1002/jum.15163. Obstetric Ultrasound Examinations. Journal of Ultrasound in Medicine. 2019;38(12):3093 AIUM Practice Parameter for the Performance of Detailed Second‐ 2014;69(8):453- Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal Imaging. Obstetrical & Gynecological Survey. Reaffirmed 2019. doi:10.1097/01.AOG.0000451759.90082.7b. Practice Bulletin No. 145: Antepartum Fetal Surveillance. Obstet Gynecol. 2014;124(1):182 -192. Reaffirmed 2018. doi:10.1097/AOG.0000000000001815. Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstet Gynecol. 2016;128(6):e241 For current preterm labor See labor preterm current For anomaly, then echo may beindicated. may echo then anomaly, cardi for suspicious hadfindings pregnancy current the or fetus demised the either on scan anatomy if or the detailed onautopsy, anomaly cardiac had aconfirmed ec for of recommendation mention anindication not is of stillbirth A history loss pregnancy weeks two prior before or 32weeks at (CPT BPP Weekly sta F at scan ≥ anatomic Fetal    pregnancy a singleton in ultrasound transvaginal a on found cm) is (2.5 mm cervix ≤25 short or funneling If 3- every performed Star For initial imaging For ollow up u up ollow 9.10 History: of Stillbirth

eviCore healthcare. All Rights Reserved. rting at 23 to 24 weeks or two weeks before prior pregnancy loss. pregnancy prior before weeks two or 24weeks at 23 to rting and/or Note: CPT Note: CPT CPT ting after the fetal anatomic scan at ≥ at scan fetalanatomic the after ting not CPT CPT and/or yet been performed, not has ultrasound complete CPT

® ® already been performed and beenperformed already

® ® ® 76817 and/or CPT and/or 76817 beperformed may 76816

76815 ( 76815 CPT [plus 76801 76817 for a transvaginal ultrasound or ultrasound a transvaginal for 76817 - - ltrasound (CPT ltrasound and low 455. doi:10.1097/01.ogx. ® 76815 should not be done on same date of service as CPT service of date doneonsame be not 76815 should Imaging - Grady AJ, Hornberger LK, et al. Diagnosis and Treatment of Fetal Cardiac limited ® - : 6 weeks until delivery 6 until weeks risk women for preterm birth prevention. American Journal of Obstetrics and 76818 or CPT or 76818

Guidelines 16 weeks (CPT 16 weeks

ultrasound) ® ® ® 76816) every 2 to 4 weeks to assess fetal growth fetal 2 assess to every to 4weeks 76816) 76802 for each additional fetus] if anda if weeks <14 fetus] additional each for 76802 76815 every 1 to 2 weeks until 32 weeks 32weeks 1to until 2 weeks every 76815 OB

- - ® 0000453817.62105.4a ho 2242. doi:10.1161/01.cir.0000437597.44550.5d . .3: Current Preterm Labor Preterm Current 18.3: after a complete ultrasound every 3 to 4weeks 3to every ultrasound acomplete after 76819) 76819)

≥ can be performed for dating if an ultrasound anultrasound if dating for can beperformed – 14 weekand just detailed anatomy US. fetus US. demised If detailed anatomy just for fetal echo. Per 2020 ACOG bulletin– 2020ACOG Per fetalecho. for ® 23 weeks, ultrasound (CPT 23 ultrasound weeks, 76811) or

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76816) can be can 76816) Page 42of109 - e256. - ® 3100. 76816 - e207. V3 no ac .0

Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

8. Cavazos-Rehg PA, Krauss MJ, Spitznagel EL, et al. Maternal Age and Risk of Labor and Delivery Complications. Maternal and Child Health Journal. 2014;19(6):1202-1211. doi:10.1007/s10995-014- 1624-7. 9. ACOG Committee Opinion No. 807: Tobacco and Nicotine Cessation During Pregnancy. Obstetrics & Gynecology. 2020;135(5). doi:10.1097/aog.0000000000003822. 10. Machado JDB, Filho PV, Petersen GO, Chatkin JM. Quantitative effects of tobacco smoking exposure on the maternal-fetal circulation. BMC Pregnancy and Childbirth. 2011;11(1). doi:10.1186/1471-2393- 11-24. 11. Hackshaw A, Rodeck C, Boniface S. Maternal smoking in pregnancy and birth defects: a systematic review based on 173 687 malformed cases and 11.7 million controls. Human Reproduction Update. 2011;17(5):589-604. doi:10.1093/humupd/dmr022. 12. Metz TD, Borgelt LM. Marijuana Use in Pregnancy and While Breastfeeding. Obstetrics & Gynecology. 2018;132(5):1198-1210. doi:10.1097/aog.0000000000002878. 13. ACOG Committee Opinion No. 722: Marijuana Use During Pregnancy and Lactation. Obstetrics & Gynecology. 2017;130(4). doi:10.1097/aog.0000000000002354. 14. ACOG Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstetrics & Gynecology. 2017;130(2). doi:10.1097/aog.0000000000002235. 15. ACOG Committee Opinion No. 479: Methamphetamine Abuse in Women of Reproductive Age. Obstetrics & Gynecology. 2011;117(3):751-755. Reaffirmed 2017. doi:10.1097/aog.0b013e318214784e . 16. ACOG Practice Bulletin No. 90: Asthma in Pregnancy. Obstetrics & Gynecology. 2008;111(2, Part 1):457-464. Reaffirmed 2019. doi:10.1097/aog.0b013e3181665ff4. 17. ACOG Practice Bulletin No. 78: Hemoglobinopathies in Pregnancy. Obstetrics & Gynecology. 2007;109(1):229-238. Reaffirmed 2018. doi:10.1097/00006250-200701000-00055. 18. ACOG Practice Bulletin No. 223: Thyroid Disease in Pregnancy. Obstetrics & Gynecology. 2020;135(6). doi:10.1097/aog.0000000000003894 19. Egan N, Bartels Ä, Khashan A, et al. Reference standard for serum bile acids in pregnancy. BJOG: An International Journal of Obstetrics & Gynaecology. 2012;119(4):493-498. doi:10.1111/j.1471- 0528.2011.03245.x. 20. Getahun D, Fassett MJ, Longstreth GF, et al. Association between maternal inflammatory bowel disease and adverse perinatal outcomes. Journal of Perinatology. 2014;34(6):435-440. doi:10.1038/jp.2014.41. 21. ACOG Committee Opinion No. 776. Immune modulating therapies in pregnancy and lactation. Obstetrics & Gynecology. 2019;133(4):846-849. doi:10.1097/aog.0000000000003177. 22. ACOG Practice Bulletin No 156. Obesity in Pregnancy. Obstetrics & Gynecology. 2015;126(6).

Reaffirmed in 2018. doi:10.1097/aog.0000000000001211. 23. Schuster M, Madueke-Laveaux OS, Mackeen AD, Feng W, Paglia MJ. The effect of the MFM obesity protocol on cesarean delivery rates. American Journal of Obstetrics and Gynecology. 2016;215(4). doi:10.1016/j.ajog.2016.05.005. 24. ACOG. Committee Opinion No. 784: Management of Patients in the Context of Zika Virus. Obstetrics & Gynecology. 2019;134(3). doi:10.1097/aog.0000000000003399. 25. Boelig RC, Saccone G, Bellussi F, Berghella V. MFM guidance for COVID-19. American Journal of Obstetrics & Gynecology MFM. 2020:100106. doi:10.1016/j.ajogmf.2020.100106. 26. ACOG/SMFM Outpatient Assessment and Management for Pregnant Women With Suspected or Confirmed Novel Coronavirus (COVID-19). https://s3.amazonaws.com/cdn.smfm.org/media/2263/COVID-19_Algorithm5.pdf 27. ACOG Practice Bulletin No. 201: Pregestational Diabetes Mellitus. Obstetrics & Gynecology. 2018;132(6). doi:10.1097/aog.0000000000002960. 28. ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus. Obstetrics & Gynecology. 2018;131(2). doi:10.1097/aog.0000000000002501. 29. ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstetrics & Gynecology. 2019;133(1). doi:10.1097/aog.0000000000003020. 30. ACOG Practice Bulletin No. 222: Gestational Hypertension and Preeclampsia. Obstetrics & Gynecology. 2020;135(6). doi:10.1097/aog.0000000000003891. 31. ACOG Practice Bulletin No. 204: Fetal Growth Restriction. Obstetrics & Gynecology. 2019;133(2). doi:10.1097/aog.0000000000003070. Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

32. Sciscione AC, Hayes EJ. Uterine artery Doppler flow studies in obstetric practice. American Journal of Obstetrics and Gynecology. 2009;201(2):121-126. doi:10.1016/j.ajog.2009.03.027. 33. Martins JG, Biggio JR, Abuhamad A. Society for Maternal-Fetal Medicine (SMFM) Consult Series #52: Diagnosis and Management of Fetal Growth Restriction. American Journal of Obstetrics and Gynecology. 2020. doi:10.1016/j.ajog.2020.05.010. 34. ACOG. Practice Bulletin No. 171: Management of Preterm Labor. Obstetrics & Gynecology. 2016;128(4). Reaffirmed 2018. doi:10.1097/aog.0000000000001711. 35. Yang J, Baer RJ, Berghella V, et al. Recurrence of Preterm Birth and Early Term Birth. Obstetrics & Gynecology. 2016;128(2):364-372. doi:10.1097/aog.0000000000001506. 36. Lengyel CS, Ehrlich S, Iams JD, Muglia LJ, Defranco EA. Effect of Modifiable Risk Factors on Preterm Birth: A Population Based-Cohort. Maternal and Child Health Journal. 2016;21(4):777-785. doi:10.1007/s10995-016-2169-8. 37. Practice Bulletin No. 130. Prediction and Prevention of Preterm Birth. Obstetrics & Gynecology. 2012;120(4):964-973. Reaffirmed 2018. doi:10.1097/aog.0b013e3182723b1b. 38. SMFM Statement: Use of 17-alpha hydroxyprogesterone caproate for prevention of recurrent preterm birth. American Journal of Obstetrics and Gynecology. 2020. doi:10.1016/j.ajog.2020.04.001. 39. Blackwell SC, Gyamfi-Bannerman C, Biggio JR Jr, et al. 17-OHPC to Prevent Recurrent Preterm Birth in Singleton Gestations (PROLONG Study): A Multicenter, International, Randomized Double- Blind Trial. Am J Perinatol. 2020;37(2):127–136. doi:10.1055/s-0039-3400227 40. Obstetric Care Consensus No. 10: Management of Stillbirth. Obstetrics & Gynecology. 2020;135(3). doi:10.1097/aog.0000000000003719. 41. Gardosi J, Madurasinghe V, Williams M, Malik A, Francis A. Maternal and fetal risk factors for stillbirth: population based study. Bmj. 2013;346(jan24 3). doi:10.1136/bmj.f108.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-10: High Risk Medications and Substances OB-10.1: Medications and Substances that Qualify for a Detailed Fetal Anatomic Scan 46

OB -10.1: Medications and Substances that Qualify for a Detailed Fetal Anatomic Scan  A detailed fetal anatomy ultrasound (CPT® 76811) is indicated for maternal use of the following: High Risk Medications/Substances Alcohol Aminoglycosides (amikacin, gentamycin, kanamycin, tobramycin, and other mycins) Amphetamines Angiotensin II antagonists or blockers Anti-neoplastics (cancer drugs) Accutane/isoretinoin/retinoic acid Aspirin – only if exposed less than 10 weeks gestation Atenolol ACE inhibitors (benzapril, captopril, enalopril, fosinopril, lisinipril, etc) Anticonvulsants (phenytoin, carbamazepine, valproate, primidone, phenobarbital, Dilantin) Azathioprine Benzodiazepines (Diazepam (valium), etc) Carbon monoxide Chlordiazepoxide Cocaine Codeine Cortisone Coumadin/ warfarin Cyclophosphamide Cytarabine Daunorubicin Dextroamphetamine Ergotamine Fluconazole (and other anti-fungals)

Heparin Lead Leflunomide Lithium Methimazole Methotrexate Methyl mercury Misoprostol Mycophenolate mofetil Oral contraceptives Paramethadione Penicillamine Primidone Progesterones (exposure less than 12 weeks) and anti-progesterone drug RU486 Pregabalin/Lyrica Quinine Retinoic acid/retinoid medications Selective serotonin reuptake inhibitors (SSRI)

Substance abuse (heroin, methadone, subutex, cocaine, marijuana/cannabinoids) Imaging Ultrasound Obstetrical

High Risk Medications/Substances Tetracyclines Thalidomide Trifluroperazine Trimethadione Valproic acid  If another high risk indication see appropriate guideline for any further imaging Practice Note There may be other medications or drugs not included on this list that cause increased risk in pregnancy. These cases should be sent for Medical Director Review.  Several studies noted lower birth weights among offspring exposed to marijuana. These findings were more pronounced among women who used more marijuana, particularly during the first and second trimesters (at least weekly during the pregnancy). CPT® 76811 may be indicated, however, given the limited evidence for antenatally detected abnormal growth, serial growth ultrasounds may not be indicated in the absence of other findings concerning for growth restriction.  In circumstances where the individual is deemed to have an increased risk for a fetal abnormality and does not have access to a provider who can perform the more desirable fetal and maternal ultrasound with detailed fetal anatomic examination (CPT® 76811) due to geographic or other constraints, a standard (after first trimester) fetal and maternal ultrasound (CPT® 76805) may be authorized instead.

References 1. ACOG Practice Bulletin No. 92: Use of Psychiatric Medications During Pregnancy and Lactation. Obstet Gynecol. 2008;111(4):1001-1020. Reaffirmed 2018. doi:10.1097/AOG.0b013e31816fd910. 2. Burkey BW, Holmes AP. Evaluating Medication Use in Pregnancy and Lactation: What Every Pharmacist Should Know. The Journal of Pediatric Pharmacology and Therapeutics. 2013;18(3):247- 258. doi:10.5863/1551-6776-18.3.247 3. ACOG Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstetrics & Gynecology. 2017;130(2):e81-e94. doi:10.1097/aog.0000000000002235. 4. Schaefer C, Peters PWJ, Miller RK. Drugs during Pregnancy and Lactation: Treatment Options and Risk Assessment. 3rd ed. London: Elsevier/Academic Press; 2015. 5. ACOG Committee Opinion No. 776 Immune Modulating Therapies in Pregnancy and Lactation. Obstetrics & Gynecology. 2019;133(4):846-849. doi:10.1097/aog.0000000000003177. 6. ACOG Committee Opinion No. 722: Marijuana Use During Pregnancy and Lactation. Obstetrics & Gynecology. 2017;130(4). doi:10.1097/aog.0000000000002354.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-11: Multiple Gestations OB-11.1: Suspected Multiple Gestations 49 OB-11.2: Known Dichorionic Multiple Gestations 49 OB-11.3: Known Monochorionic-Diamniotic or Monochorionic- Monoamniotic Multiple Gestations 50

OB -11.1: Suspected Multiple Gestations For Suspected multiple pregnancies:  CPT® 76801 [plus CPT® 76802 for each additional fetus] and/or CPT® 76817 if a complete ultrasound has not yet been performed and is <14 weeks, or  CPT® 76815 and/or CPT® 76817 can be performed for dating if an ultrasound not already been performed and ≥14 week and <16 weeks, or  CPT® 76805 and CPT® 76810 for each additional fetus if ≥14 weeks if a dating ultrasound or a complete anatomy ultrasound has not yet been performed during this pregnancy

OB-11.2: Known Dichorionic Multiple Gestations For Known dichorionic multiple pregnancies:  CPT® 76811 and CPT® 76812 for each additional fetus at ≥16 weeks if a complete detailed anatomic scan (CPT® 76811) has not yet been performed during this pregnancy. If requested prior to 16 weeks, send to Medical Director Review.  Growth ultrasound (CPT® 76816) can be performed every 4 to 6 weeks after diagnosis.  Universal cervical length (CL) screening with transvaginal ultrasound (CPT® 76817) is NOT recommended in twin gestations. However, transvaginal ultrasound (CPT® 76817) may be considered if the cervical length (CL) is <3.6 cm on trans-abdominal ultrasound (as with singleton pregnancies – See OB-7.1: Fetal Anatomic Scan), or in certain circumstances of poor visualization with trans-abdominal ultrasound. Send all these requests to Medical Director Review.  BPP (CPT® 76818 or CPT® 76819) or modified BPP (CPT® 76815) may be performed starting at 32 weeks or sooner if additional risk factors  If FGR or growth discordance ≥20% is diagnosed, can perform: UA Doppler (CPT® 76820) weekly  If UA Dopplers are abnormal (significantly elevated or absent or reversed end diastolic flow), then more frequent testing (twice per week or even daily) BPPs (CPT® 76818 or CPT® 76819) and/or UA Dopplers (CPT® 78620) may be considered. Send all these requests to Medical Director Review.  If IVF dichorionic twins, report initial fetal echo as CPT® 76825 and/or CPT® 76827 with or without CPT® 93325. Trans-abdominal fetal echo is usually not performed prior to 16 weeks. See OB-12.3: Indications for Maternal Conditions  If other high risk factors, See OB-9: High Risk Pregnancy

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB -11.3: Known Monochorionic-Diamniotic or Monochorionic- Monoamniotic Multiple Gestations For Known monochorionic-diamniotic or monochorionic-monoamniotic multiple pregnancies  CPT® 76811 and CPT® 76812 for each additional fetus if ≥16 weeks and a complete detailed anatomic scan (CPT® 76811) has not yet been performed (if earlier send to Medical Director Review).  Universal cervical length (CL) screening with transvaginal ultrasound (CPT® 76817) is NOT recommended in twin gestations. However, transvaginal ultrasound (CPT® 76817) may be considered if the cervical length (CL) is <3.6 cm on trans-abdominal ultrasound (as with singleton pregnancies – See OB-7.1: Fetal Anatomic Scan), or in certain circumstances of poor visualization with trans-abdominal ultrasound. Send all these requests to Medical Director Review.  CPT® 76816 (growth ultrasound) every 2 to 4 weeks starting at 16 weeks  Fetal echo (CPT® 76825 and/or CPT® 76827) with or without color Doppler (CPT® 93325) is indicated (usually not performed <16 weeks).  Send all follow-up echo requests (CPT® 76826 and/or CPT® 76828) to Medical Director Review.  MCA Doppler (CPT® 76821) and limited ultrasound (CPT® 76815) is indicated every 2 weeks starting at 16 weeks until delivery to monitor for Twin-Twin Transfusions Syndrome (TTTS) and/or Twin Anemia Polycythemia Sequence (TAPS).  If findings are suspicious for developing TTTS, more frequent imaging may be indicated, send to Medical Director Review.  BPP (CPT® 76818 or CPT® 76819) or modified BPP (CPT® 76815) may be performed weekly starting at 32 weeks or sooner if additional risk factors  If TTTS is diagnosed, up to daily evaluation can be performed to aid in planning intervention and/or imminent delivery. In these cases, may perform: Limited ultrasound (CPT® 76815), and/or BPP (CPT® 76818 or CPT® 76819) if >26 weeks or UA Doppler (CPT® 76820) and/or MCA Doppler (CPT® 76821)  If FGR or growth discordance >20% is diagnosed, can perform: UA Doppler (CPT® 76820) weekly  If UA Dopplers are abnormal (significantly elevated or absent or reversed end diastolic flow), then more frequent testing (twice per week or even daily) BPPs (CPT® 76818 or CPT® 76819) and/or UA Dopplers (CPT® 78620) may be considered. Send these requests to Medical Director Review.  If other high risk factors, See OB-9: High Risk Pregnancy  Triplets or higher order Multiple Pregnancy receive same imaging as monochorionic- diamniotic twins. These requests will be forwarded for Medical Director Review. Practice Notes  Birth weight discordance = (larger twin weight minus smaller twin weight) divided larger twin weight × 100.  Universal CL screening with transvaginal ultrasound (CPT® 76817) is NOT recommended in twin gestations. In addition, Per ACOG - Cerclage placement (prophylactic or rescue) should be avoided in multifetal pregnancies. However, because several studies have shown that a one-time CL measurement ≤20 mm at Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

18-24 weeks may be an accurate predictor of preterm birth in multiple gestation, and because progesterone therapy might reduce the risk of neonatal morbidity and mortality associated with PTB, then a one-time transvaginal CL assessment may be considered if trans-abdominal CL measures ≤3.6 cm (as with singleton gestation- See: OB-7.1: Fetal Anatomic Scan). Transvaginal ultrasound (CPT® 76817) may be considered if the cervical length (CL) is ≤3.6 cm on trans-abdominal ultrasound (as with singleton pregnancies- See OB-7.1: Fetal Anatomic Scan), or in certain circumstances of poor visualization with trans-abdominal ultrasound.  TTTS is diagnosed by the ultrasound findings of polyhydramnios in one twin (the recipient) and oligohydramnios in the other twin (the donor). If AFI is discordant between the twins (low but not <2 cm in one and/or high but not >8 cm in the other); weekly imaging (MCA and/or limited US) may be indicated to ensure not developing TTTS.  Fetal loss of one twin during the first trimester does not appear to increase the risk of FGR or preterm delivery in the surviving twin, however, loss of one or more fetus(es) after 17 weeks gestation is associated with increased risk for FGR and PTB and should be imaged according to OB-11: Multiple Gestations. Monochorionic twin pregnancies with demise of one twin after 17 weeks have up to an 18% chance of major morbidity or mortality for the remaining fetus, these cases should be sent for Medical Director Review.  In circumstances where CPT® 76811 cannot be performed See OB-1.3: Ultrasound Code Selection

References 1. ACOG Practice Bulletin No. 169: Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies. Obstet Gynecol. 2016;128(4):e131-e146. Reaffirmed 2019. doi:10.1097/AOG.0000000000001709.

2. ACOG Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstet Gynecol. 2016;128(6):e241-e256. Reaffirmed 2018. doi:10.1097/AOG.0000000000001815. 3. Khalil A, Rodgers M, Baschat A, et al. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. Ultrasound in Obstetrics & Gynecology. 2016;47(2):247-263. doi:10.1002/uog.1582. 4. ACOG Practice Bulletin No. 130: Prediction and Prevention of Preterm Birth. Obstet Gynecol. 2012;120(4):964-973. Reaffirmed 2016. doi:10.1097/AOG.0b013e3182723b1b. 5. ACOG Practice Bulletin No. 142: Cerclage for the Management of Cervical Insufficiency. Obstet Gynecol. 2014;123(2, PART 1):372-379. Reaffirmed 2019. doi:10.1097/01.aog.0000443276.68274.cc. 6. Rafael TJ, Berghella V, Alfirevic Z. Cervical stitch (cerclage) for preventing preterm birth in multiple pregnancy. Cochrane Database of Systematic Reviews. September 2014. doi:10.1002/14651858.cd009166.pub2. 7. Razaz N, Avitan T, Ting J, Pressey T, Joseph K. Perinatal outcomes in multifetal pregnancy following fetal reduction. Canadian Medical Association Journal. 2017;189(18). doi:10.1503/cmaj.160722. 8. Mcintosh J, Feltovich H, Berghella V, Manuck T. The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. Society for Maternal-Fetal Medicine (SMFM) Consult Series #40. American Journal of Obstetrics and Gynecology. 2016;215(3). doi:10.1016/j.ajog.2016.04.027. 9. Practice Committee of American Society for Reproductive Medicine: Multiple gestation associated with infertility therapy: an American Society for Reproductive Medicine Practice Committee opinion. Fertility and Sterility. 2012;97(4):825-834. doi:10.1016/j.fertnstert.2011.11.048. Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

10. Slaghekke F, Pasman S, Veujoz M, et al. Middle cerebral artery peak systolic velocity to predict fetal hemoglobin levels in twin anemia-polycythemia sequence. Ultrasound in Obstetrics & Gynecology. 2015;46(4):432-436. doi:10.1002/uog.14925. 11. Lopriore E, Slaghekke F, Oepkes D, Middeldorp JM, Vandenbussche FP, Walther FJ. Clinical outcome in neonates with twin anemia-polycythemia sequence. American Journal of Obstetrics and Gynecology. 2010;203(1). doi:10.1016/j.ajog.2010.02.032. 12. Slaghekke F, Kist W, Oepkes D, et al. Twin Anemia-Polycythemia Sequence: Diagnostic Criteria, Classification, Perinatal Management and Outcome. Fetal Diagnosis and Therapy. 2010;27(4):181- 190. doi:10.1159/000304512. 13. Tollenaar LSA, Slaghekke F, Middeldorp JM, et al. Twin Anemia Polycythemia Sequence: Current Views on Pathogenesis, Diagnostic Criteria, Perinatal Management, and Outcome. Twin Research and Human Genetics. 2016;19 (3):222-233. doi:10.1017/thg.2016.18. 14. ACOG Practice Bulletin No. 204: Fetal Growth Restriction. Obstet Gynecol. 2019;133(2):e97-e109. doi:10.1097/AOG.0000000000003070. 15. Martins JG, Biggio JR, Abuhamad A. Society for Maternal-Fetal Medicine (SMFM) Consult Series #52: Diagnosis and Management of Fetal Growth Restriction. American Journal of Obstetrics and Gynecology. 2020. doi:10.1016/j.ajog.2020.05.010 16. Simpson LL. Twin-twin transfusion syndrome. American Journal of Obstetrics and Gynecology. 2013;208(1):3-18. doi:10.1016/j.ajog.2012.10.880. 17. Lanna MM, Consonni D, Faiola S, et al. Incidence of Cerebral Injury in Monochorionic Twin Survivors after Spontaneous Single Demise: Long-Term Outcome of a Large Cohort. Fetal Diagnosis and Therapy. 2019;47(1):66-73. doi:10.1159/000500774.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-12: Fetal Echocardiography (ECHO) OB-12.1: Fetal Echocardiography – Coding 54 OB-12.2: Indications for Fetal Conditions 54 OB-12.3: Indications for Maternal Conditions 55 OB-12.4: Medication or Drug Exposure 55

OB -12.1: Fetal Echocardiography – Coding  Transabdominal fetal echo is usually not performed prior to 16 weeks. If ordered prior to 16 weeks send to Medical Director Review.  Fetal echocardiography (Initial study-CPT® 76825 or follow-up-CPT® 76826) and Doppler echocardiography (Initial study-CPT® 76827 or follow-up-CPT® 76828) and/or Doppler color flow velocity mapping (CPT® 93325) can be ordered together or separately for the following conditions:

OB-12.2: Indications for Fetal Conditions  Known or suspected abnormal fetal cardiac evaluation on fetal anatomic scan. Known or suspected abnormality must be documented as hard copy or acknowledged verbally by provider of known or suspected fetal cardiac evaluation Suboptimal cardiac evaluation alone is not an indication for fetal echogram. If the 4-chamber view is adequate and there is no other suspicion of a cardiac abnormality, a fetal echocardiogram is not considered medically necessary. A follow up ultrasound (CPT® 76815 or CPT® 76816) is indicated for suboptimal visualization.  Fetal cardiac arrhythmia; sustained fetal tachycardia or bradyarrhythmia  Major fetal extra-cardiac anomaly, (excluding soft markers for aneuploidy: for example shortened long bones, pyelectasis, echogenic bowel, hypoplastic nasal bone, cardiac echogenic foci and choroid plexus cyst) See OB-9.2: High Risk Group Two – Findings on Ultrasound that May Require Further Imaging.  Congenital heart disease (CHD) in a 1st degree relative of the fetus (i.e. CHD in the mother, father, or sibling of the fetus)  Known fetal chromosomal abnormalities (fetal aneuploidy) or ultrasound findings of a suspected chromosomal abnormality (excluding soft markers as only ultrasound findings)  Single umbilical artery  Chorioangioma or Umbilical cord varix (if suspicion of fetal hydrops)  Fetal intra-abdominal venous anomaly (persistent right umbilical vein)  Fetal effusion (pericardial, pleural effusion, ascites, etc.)  Fetal hydrops, See OB-16: Alloimmunization/Rh Isoimmunization/Other Causes of Fetal Anemia/Parvo/Hydrops  Monochorionic twins/TTTS  Abnormal Fetal Nuchal Translucency scan (≥3.0mm) during current pregnancy.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

if there are other suspicious findings on an anatomy scan. Send to Medical Director Review.  An initial echo, CPT® 76825 and CPT® 76827 are performed only once per fetus/per facility (i.e. Maternal Fetal Medicine versus Pediatric Cardiology request)  The minimal use of color Doppler (CPT® 93325) alone, when performed for anatomical structure identification during a standard ultrasound procedure, is not separately reimbursable.  Procedure code (CPT® 76827 or CPT® 76828) includes the evaluation of veins, arteries, and valves. Guidelines do not support the billing of an additional code (CPT® 76820/CPT® 76821) References 1. Donofrio MT, Moon-Grady AJ, Hornberger LK, et al. Diagnosis and Treatment of Fetal Cardiac Disease. Circulation. 2014;129(21):2183-2242. doi:10.1161/01.cir.0000437597.44550.5d. 2. Brucato A. Prevention of congenital heart block in children of SSA-positive mothers. Rheumatology. 2008;47(Supplement 3):iii35-iii37. doi:10.1093/rheumatology/ken153. 3. Mcbride KL, Garg V. Impact of Mendelian inheritance in cardiovascular disease. Annals of the New York Academy of Sciences. 2010;1214(1):122-137. doi:10.1111/j.1749-6632.2010.05791.x, 4. Reddy UM, Abuhamad AZ, Levine D, et al. Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society of Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Obstet Gynecol Survey. 2014;69(8):453-455. 5. Lee W, Allan L, Carvalho JS, et al. ISUOG consensus statement: what constitutes a fetal echocardiogram? Ultrasound in Obstetrics and Gynecology. 2008;32(2):239-242. doi:10.1002/uog.6115. 6. Friedman DM, Kim MY, Copel JA, et al. Utility of Cardiac Monitoring in Fetuses at Risk for Congenital Heart Block. The PR Interval and Dexamethasone Evaluation (PRIDE) Prospective Study. Circulation. 2008;117(4):485-493. doi:10.1161/circulationaha.107.707661 7. AIUM Practice Parameter for the Performance of Fetal Echocardiography. Journal of Ultrasound in Medicine. 2019;39(1). doi:10.1002/jum.15188.

8. Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Care & Research. 2020;72(4):461-488. doi:10.1002/acr.24130. 9. Jenkins KJ, Correa A, Feinstein JA, et al. Noninherited Risk Factors and Congenital Cardiovascular Defects: Current Knowledge. Circulation. 2007;115(23):2995-3014. doi:10.1161/circulationaha.106.183216. . Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-13: Fetal MRI OB-13.1: Indications for Fetal MRI 58

OB -13.1: Indications for Fetal MRI CPT® Code Guidance  Fetal MRI (CPT® 74712); for each additional fetus (CPT® 74713)  Do not report CPT® 74712 and CPT® 74713 in conjunction with CPT® 72195, CPT® 72196, CPT® 72197  If only placenta or maternal pelvis is imaged without fetal imaging, use MRI Pelvis (CPT® 72195)  Fetal MRI (CPT® 74712) [plus CPT® 74713 for each additional fetus] may be considered for assessment of known or suspected fetal/pregnancy abnormalities for surgical planning, and/or if an ultrasound is equivocal and additional information is needed for counseling purposes, for indications which may include the following:  Brain  Congenital anomalies  ventriculomegaly  corpus callosal dysgenesis  holoprosencephaly  posterior fossa anomalies  malformations of cerebral cortical development  microcephaly  Screening fetuses with a family risk for brain anomalies  tuberous sclerosis  corpus callosal dysgenesis  malformations of cerebral cortical development  Vascular abnormalities  vascular malformations  hydranencephaly  Intra-uterine cerebrovascular accident (CVA) Spine  Congenital anomalies  neural tube defects  sacrococcygeal teratomas  caudal regression/sacral agenesis  syringomyelia  vertebral anomalies  Skull, face, and neck  Masses of the face and neck  venolymphatic malformations  hemangiomas  goiter  teratomas  facial clefts  Airway obstruction  conditions that may impact parental counseling, prenatal management, delivery planning, and postnatal therapy  Thorax

 Masses Imaging Ultrasound Obstetrical

 congenital pulmonary airway malformations (congenital cystic adenomatoid malformation; sequestration, and congenital lobar emphysema);  congenital diaphragmatic hernia  effusion  Volumetric assessment of lung  cases at risk for pulmonary hypoplasia secondary to oligohydramnios, chest mass, or skeletal dysplasias  Abdomen, retroperitoneal and pelvis  Bowel anomalies such as megacystis microcolon  Abdominal wall defect  Mass  abdominal–pelvic cyst  tumors (e.g. hemangiomas, neuroblastomas, sacrococcygeal teratomas, and suprarenal or renal masses)  Complex genitourinary anomalies (e.g. cloaca)  Congenital Heart Disease (CHD)  Skeletal dysplasia  Multiple malformations  Complications of monochorionic twins/TTTS (eg. Laser treatment of twins, demise of one twin, conjoined twins) Any suspected fetal anomaly associated with severe oligohydramnios or anhydramnios References 1. Saleem SN. Fetal MRI: An approach to practice: A review. Journal of Advanced Research. 2014;5(5):507-523. doi:10.1016/j.jare.2013.06.001. 2. Prayer D, Malinger G, Brugger PC, et al. ISUOG Practice Guidelines: performance of fetal magnetic resonance imaging. Ultrasound in Obstetrics & Gynecology. 2017;49(5):671-680. doi:10.1002/uog.17412.

3. Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal Imaging: Executive Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Obstetrics & Gynecology. 2014;123(5):1070-1082. doi:10.1097/aog.0000000000000245. 4. American College of Radiology (ACR) and the Society for Pediatric Radiology (SPR). Practice Parameters by Modality | American College of Radiology: Practice Parameter for the Safe And Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). American College of Radiology | American College of Radiology. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/MR- Fetal.pdf. Published 2015. (Resolution 11). 5. American College of Obstetricians and Gynecologists Committee Opinion No. 723. Guidelines for diagnostic imaging during pregnancy and lactation. Obstetrics & Gynecology. 2017;130(4). doi:10.1097/aog.0000000000002355 Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-14: Abnormal Fetal Position/ Presentation OB-14.1: Abnormal Fetal Position or Presentation 61

OB -14.1: Abnormal Fetal Position or Presentation  To confirm suspected abnormal fetal position or presentation (transverse or breech presentation) at ≥36 weeks gestation, report one of the following:  CPT® 76805 (plus CPT® 76810 for each additional fetus) when complete anatomy scan has not yet been performed in the pregnancy or  CPT® 76815 for limited ultrasound to check fetal position or CPT® 76816 if version is being considered and/or for delivery planning Practice Note  Fetal presentation should be assessed by abdominal palpation at 36 weeks or later, when presentation is likely to influence the plans for the birth. Routine assessment of presentation by abdominal palpation before 36 weeks is not always accurate. Suspected fetal malpresentation should be confirmed by an ultrasound assessment. An ultrasound can be performed at ≥36 weeks gestation to determine fetal position to allow for external cephalic version. Ultrasound to determine fetal position is not necessary prior to 36 weeks gestation unless delivery is imminent.  Though rarely used anymore, there may still be occasional planned vaginal delivery of a breech presentation. There is not enough evidence to support the use of X-ray pelvimetry for deciding on mode of delivery in women whose fetuses have a cephalic presentation. However, pelvimetry in breech presentation may allow for better selection of the delivery route, with a significantly lower emergency caesarean‐ section rate noted in small trials. Send all pelvimetry requests to Medical Director Review. References 1. ACOG Practice Bulletin No. 221: External Cephalic Version. Obstetrics & Gynecology. 2020;135(5). doi:10.1097/aog.0000000000003837. 2. Safe Prevention of the Primary Cesarean Delivery. Obstetric Care Consensus No. 1. Obstetrics & Gynecology. 2014;123(3):693-711. Reaffirmed 2018. doi:10.1097/01.aog.0000444441.04111.1d.

3. Pattinson RC, Cuthbert A, Vannevel V. Pelvimetry for fetal cephalic presentations at or near term for deciding on mode of delivery. Cochrane Database of Systematic Reviews. 2017. doi:10.1002/14651858.cd000161.pub2 Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-15: Adnexal Mass/Uterine Fibroids and Uterine Anomalies OB-15.1: Adnexal Mass 63 OB-15.2: Uterine Fibroids in Pregnancy 63 OB-15.3: Uterine Anomalies in Pregnancy 64

______©2020 eviCore healthcare. All Rights Reserved. Page 62 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______  OB- malignancy. with associated typically CA of Levels - in only1.2 cysts. or paraovarian luteum and corpus teratomas mature are adnexalmass of The majority Practice OB- Obstetrical Ultrasound ©2020       size: any of fibroid(s) Submucosal  below: as indicated 5cmwould be isof and imaging andone3cm total cm fibroid, one than more If See ultrasound MRI ultra initial the Following For 15.2: Uterine 15.1: Adnexal Mass

eviCore healthcare. All Rights Reserved.  CPT    is placentation If First trimester: CPT   ( Moderate establish dates if < if dates establish certain circumstances certain CPT CPT yet beenperformed, not has scan anatomic CPT CPT yet beenperformed not has scan anatomic CPT performed CPT CPT

a known or suspected adnexal/pelvic mass adnexal/pelvic suspected a knownor PV P Note Fetal anatomic scan (CPT scan anatomic Fetal to establish dates establish to (CPT If See CPT F F and 24weeks, to 16 between CPT elvis (CPT elvis 6.8% of pregnant patients with persistent mass. persistent with patients pregnant of 6.8% ® ollow up u up ollow u up ollow the fibroid is in the lower uterine segment or cervical fibroid then ultrasound ultrasound fibroid then cervical or segment uterine lower isin the fibroid the - ® ® ® ® ® ® ®

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

Practice Note  Though pregnancy seems to have little or no effect on the overall size of fibroids, Fibroids affect pregnancy and delivery in several ways, with abdominal pain, miscarriage, malpresentation, and difficult delivery being the most frequent complications. These complications relate to preterm labor, placental abruption, fetal growth restriction, and fetal compression syndromes. The risk of preterm labor appears to correlate with the size of the fibroid (over 600 cm3) and/or the presence of multiple fibroids. Placental abruption has been reported to occur frequently in pregnancies complicated by fibroids, especially with placentation over a fibroid. Fibroid volumes >200 cm3 are more commonly associated with fetal growth restriction. Fetal compression syndrome is a direct result of large fibroids and is not commonly found with small fibroids. Finally, malposition or obstructed labor may be associated with fibroids of the lower uterine segment.

OB-15.3: Uterine Anomalies in Pregnancy  For uterine septum, uterine didelphys, unicornuate uterus, bicornuate uterus:  CPT® 76801 [plus CPT® 76802 for each additional fetus] if a complete ultrasound has not yet been performed, or  If a complete ultrasound was previously performed, CPT® 76815 and/or CPT® 76817 or  CPT® 76805 or CPT® 76811 and/or CPT® 76817 at ≥16 weeks  CPT® 76817 and/or CPT® 76815 every 2 weeks at 16 to 24 weeks (See OB- 18.1: Cervical Insufficiency)  CPT® 76816 every 3 to 6 weeks starting at ≥23 weeks  Starting at 32 weeks, weekly BPP (CPT® 76818 or CPT® 76819) or modified BPP (CPT® 76815) Practice Note

 In circumstances where the individual is deemed to have an increased risk for a fetal abnormality and does not have access to a provider who can perform the more desirable fetal and maternal ultrasound with detailed fetal anatomic examination (CPT® 76811) due to geographic or other constraints, a standard (after first trimester) fetal and maternal ultrasound (CPT® 76805) may be authorized instead.  CPT® 76811 and CPT® 76812 should only be used once per pregnancy unless the mother changes to a new medical caregiver at a new office and there is a new medical indication and/or change in condition. References 1. ACOG Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses. Obstet Gynecol. 2016;128(5):e210-e226. doi:10.1097/AOG.0000000000001768. 2. Stout M, Odibo A, Graseck A, et al. Leiomyomas at Routine Second-trimester Ultrasound Examination and Adverse Obstetric Outcomes. Obstetric Anesthesia Digest. 2012;32(1):21-22. doi:10.1097/01.aoa.0000410780.41686.41. 3. Lee HJ, Norwitz ER, Shaw J. Contemporary management of fibroids in pregnancy. Reviews in obstetrics & gynecology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876319/. Published 2010. Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

4. Shavell VI, Thakur M, Sawant A, et al. Adverse obstetric outcomes associated with sonographically identified large uterine fibroids. Fertility and Sterility. 2012;97(1):107-110. doi:10.1016/j.fertnstert.2011.10.009. 5. Kase BA, Blackwell SC. SMFM consult: Fibroids in pregnancy: Meaning and Management. Contemporary OBGYN. http://www.contemporaryobgyn.net/modern-medicine-feature-articles/smfm- consult-fibroids-pregnancy-meaning-and-management. Published December 5, 2014. 6. Sei K, Masui K, Sasa H, Furuya K. Size of uterine leiomyoma is a predictor for massive haemorrhage during caesarean delivery. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2018;223:60-63. doi:10.1016/j.ejogrb.2018.02.014 7. Penzias A, Bendikson K, Butts S, et al. Removal of myomas in asymptomatic patients to improve fertility and/or reduce miscarriage rate: a guideline. Fertility and Sterility. 2017;108(3):416-425. doi:10.1016/j.fertnstert.2017.06.034. 8. ACOG Practice Bulletin No. 142: Cerclage for the Management of Cervical Insufficiency. Obstet Gynecol. 2014;123(2, PART 1):372-379. Reaffirmed 2019. doi:10.1097/01.aog.0000443276.68274.cc. 9. Hua M, Odibo AO, Longman RE, Macones GA, Roehl KA, Cahill AG. Congenital uterine anomalies and adverse pregnancy outcomes. American Journal of Obstetrics and Gynecology. 2011;205(6). doi:10.1016/j.ajog.2011.07.022 10. Pfeifer S, Butts S, Dumesic D, et al. Uterine septum: a guideline. Fertility and Sterility. 2016;106(3):530-540. doi:10.1016/j.fertnstert.2016.05.014.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-16: Alloimmunization/Rh Isoimmunization/ Other Causes of Fetal Anemia/Parvo/Hydrops OB-16.1: Alloimmunization/Rh Isoimmunization 67 OB-16.2: Exposure to Parvovirus B-19 68 OB-16.3: Twin Anemia Polycythemia Sequence 68 OB-16.4: Other Fetal Hydrops/Nonimmune Hydrops 68 OB-16.5: Other Causes of Fetal Anemia 69

______©2020 eviCore healthcare. All Rights Reserved. Page 66 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______  Note Practice OB- Obstetrical Ultrasound   ©2020       indicated: is imaging following The     indications Alloimmunization/ for Imaging gestational age . gestational titers. Because MCA veryhigh or anemia fetal severe early of history isapast there if gestation of weeks isoimmunization/all Rhesus dueto anemia risk for at afetus evaluate to amniocentesis for substitute can a as be used artery cerebral middle fetal the of (PSV) velocity Peak systolic Wra. Wright Radin, Heibel, Good, Co2. antigen Public En, Public antigen Yt, antigen Public PPPTj, Di, Diego D1, Diego MSSsMT, MNSsMi, MNSsU, MNSss, MNSsS, MNSsM, M to cases these send Alloimmunization/Rh Isoimmunization F fetus and newborn and may require fetal assessment as in as OB assessment requirefetal may and andnewborn fetus O pregnancies. Rh+ in subsequent and/or fetus Rh+ current the cellsof blood the red destroy and placenta the cross which can antibodies causing to produce her mother anRh negative of circulation the enter blood cells red Rh+ which through fetal process the is isoimmunization/alloimmunization Rhesus fetalanemia. of causes congenital or known acquired other any non alloimmunization, Kell weeks or soonerweeks onfetal depending condition BPP (CPT weeks F toto 4weeks fetal assess growth starting after fetal (CPT anatomic scan FetalDetailed Anatomic (CPT Scan weeks CPT CPT hasultrasound notyet beenperformed, and/or CPT ofthePrior pregnancy and disease with fetus (hemolytic associated HDFN newborn) Evidence hydrops offetal onprevious imaging AntiWith When any oneofthefollowing antibody are ≥1:8 maternal titers - red as such conditions, of immune bearesult may andhydrops anemia etal .1: Alloimmunization/ 16.1: ther antigens not listed above, may be associated with hemolytic disease of the of disease hemolytic with beassociated may above, listed antigens not ther etal etal eviCore healthcare. All Rights Reserved. Anti Anti antibodies (Cc/Dd/Ee)Rhesus ® ® ®

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB -16.5: Other Causes of Fetal Anemia  A ‘one-time’ MCA Doppler (CPT® 76821) assessment may be indicated if at high risk or suspicious for fetal anemia, for example, chorioangioma, umbilical vein varix, or finding of sustained fetal tachyarrhythmia or bradyarrhythmia - See OB-12.2: Indications for Fetal Conditions and OB-21: Placental and Cord Abnormalities. Practice Notes  In circumstances where the individual is deemed to have an increased risk for a fetal abnormality and does not have access to a provider who can perform the more desirable fetal and maternal ultrasound with detailed fetal anatomic examination (CPT® 76811) due to geographic or other constraints, a standard (after first trimester) fetal and maternal ultrasound (CPT® 76805) may be authorized instead.  CPT® 76811 and CPT® 76812 should only be used once per pregnancy unless the mother changes to a new medical caregiver at a new office and there is a new medical indication and/or change in condition. References 1. ACOG Practice Bulletin No. 181. Prevention of Rh D alloimmunization. Obstet Gynecol 2017(2); 130: 57-70. doi:10.1097/aog.0000000000002232. 2. ACOG Practice Bulletin No. 192. Management of Alloimmunization During Pregnancy. Obstetrics & Gynecology. 2018;131(3):e82-e90. doi:10.1097/aog.0000000000002528. 3. Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal Imaging: Executive Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Obstetrical & Gynecological Survey. 2014;69(8):453-455. doi:10.1097/01.ogx.0000453817.62105.4a. 4. Mari G, Deter RL, Carpenter RL, et al. Noninvasive Diagnosis by Doppler Ultrasonography of Fetal Anemia Due to Maternal Red-Cell Alloimmunization. New England Journal of Medicine. 2000;342(1):9-14. doi:10.1056/nejm200001063420102. 5. Mari G, Norton ME, Stone J, et al. Society for Maternal-Fetal Medicine (SMFM) Clinical Guideline #8: The fetus at risk for anemia–diagnosis and management. American Journal of Obstetrics and Gynecology. 2015;212(6):697-710. doi:10.1016/j.ajog.2015.01.059. 6. Crane J, Mundle W, Boucoiran I, et al. Parvovirus B19 Infection in Pregnancy. Journal of Obstetrics and Gynaecology Canada. 2014;36(12):1107-1116. doi:10.1016/s1701-2163(15)30390-x. 7. ACOG. Practice Bulletin No. 151: Cytomegalovirus, parvovirus B19, varicella zoster, and toxoplasmosis in pregnancy. Obstetrics & Gynecology. 2015;125(6):1510-1525. Reaffirmed 2017. doi:10.1097/01.aog.0000466430.19823.53 8. Norton ME, Chauhan SP, Dashe JS. Society for Maternal-Fetal Medicine (SMFM) Clinical Guideline #7: nonimmune hydrops fetalis. American Journal of Obstetrics and Gynecology. 2015;212(2):127- 139. doi:10.1016/j.ajog.2014.12. 018.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-17: Amniotic Fluid Abnormalities/ Oligohydramnios/Polyhydramnios OB-17.1: Amniotic Fluid Abnormalities 71

______©2020 eviCore healthcare. All Rights Reserved. Page 70 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______    Notes Practice OB- Obstetrical Ultrasound ©2020      ≤2 cm pocket For     (MVP) pocket vertical For  For trimester) fetal and maternal ultrasound (CPT ultrasound fetalandmaternal trimester) (CPT examination anatomic fetal detailed with ultrasound andmaternal fetal desirable the more perform can who a to provider access have not anddoes abnormality afetal for risk have to anincreased isdeemed individual the where circumstances In (ECHO) Echocardiography scan. anatomy onan abnormalfindings are there if beindicated may echocardiography Fetal malformation. cardiac or arrhythmias fetal dysfunction, cardiac of a as finding may also present Polyhydramnios . Isoimmunization See not. OB or ispresent anemia fetal this fetal with associated hydrops fetal of finding presenting beanearly can Polyhydramnios medical indication and/or change and/or indication medical new a is there and office new a at caregiver medical new a to changes mother CPT s Medical Director ReviMedical CPT (If < weeks, CPT weeks CPT Director Review) CPT CPT   BPP (CPT CPT   CPT CPT  Imaging may size for beindicated preterm/prelabor unequal andor suspected dates weeks  rupture ofmembranes .1: Amniotic Fluid Abnormalities Fluid Amniotic 17.1: confirmed confirmed confirmed suspected tarting at26tarting weeks

eviCore healthcare. All Rights Reserved. Twice weeklyTwice polyhydramnios for severe Weekly for mild polyhydramnios for severeEvery 2weeks polyhydramnios >30 cm (AFI cm Every for 3to4weeks 8 cm to10 mild polyhydramnios 24cm (AFI to30cmMVP or OB OB ® anemia. Middle cerebral artery Doppler is commonly used to diagnose whether to used commonly is Doppler artery cerebral Middle anemia. ® ® ® ® ® ® ® ® ® 76811andCPT

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26 weeks send26 weeks Director toMedical Review) 76818 or CPT

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Obstetrical Ultrasound Imaging 6. 5. 4. 3. 2. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______1. References Obstetrical Ultrasound ©2020 . Gynecology. 2020. doi:10.1016/j.ajog.2020.05.010 #52: Diagnosis and Management of Fetal Growth Restriction. American Journal of Obstetrics and Martins JG, Biggio JR, Abuhamad A. Society for Maternal Macones; Published in 2017 . Committee on Obstetric Practice; Edited by Sarah J. Kilpatrick, Lu- Guidelines for Perinatal Care, 8th Edition; By AAP Committee on Fetus and Newborn and ACOG doi:10.1016/j.ajog.2018.07.016. polyhydra Dashe JS, Pressman EK, Hibbard JU. SMFM Consult Series #46: Evaluation and management of doi:10.1002/jum.15163 . Obstetric Ultrasound Examinations. Journal of Ultrasound in Medicine. 2019;38(12):3093 AIUM Practice Parameter for the Performance of Detailed Second‐ 192. Reaffirmed 2019. doi:10.1097/01.AOG.0000451759.90082.7b ACOG Practice Bulletin No. 145: Antepartum Fetal Surveillance. Obstet Gynecol. 2014;124(1):182- Reaffirm Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstet Gynecol. 2016;128(6):e241 eviCore healthcare. All Rights Reserved. ed 2018. doi:10.1097/AOG.0000000000001815. mnios. American Journal of Obstetrics and Gynecology. 2018;219(4). Imaging

Guidelines

- Fetal Medicine (SMFM) Medicine Consult Series Fetal 8924 8924 Ann Papile and George A.

. and Third ‐

Trimester Diagnostic Trimester www.eviCore.com Page 72of109 - e256. - 3100. V3 .0

Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB-18: Cervical Insufficiency/Current Preterm Labor OB-18.1: Cervical Insufficiency 74 OB-18.2: Cerclage in Place in Current Pregnancy 74 OB-18.3: Current Preterm Labor 74

______©2020 eviCore healthcare. All Rights Reserved. Page 73 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______   OB-18      OB-18 OB-18 Obstetrical Ultrasound ©2020       B CPT when symptomatic 2 weeks) every than previously performed was scan anatomic fetal acomplete if pregnancy; this during beenperformed yet not has scan CPT PLUS pregnancy(contractions in current labor Known preterm 32 until weeks (CPT Transvaginal 16 at scan weeks. CPT beenperformed not has scan anatomic CPT and/or fetus] additional each for CPT CPT first trimester(<1 CPT has not yet been performed during this pregnancy this during yet beenperformed not has CPT or in first trimester (<14 yet been performed not weeks) has ultrasound a if complete    pregnancy in asingleton cervix short or funneling If CPT CPT CPT  of any the following: For iophysical profile (BPP) (CPT (BPP) profile iophysical

.3: Current Preterm Labor .2: Cerclage .1: Cervical Insufficiency and/or Note: Note: CPT CPT [LEEP]) Procedure Excision Electrosurgical cervix to trauma Surgical delivery aprevious from laceration obstetrical Cervical cervix dilationof Over pregnancy prior cerclage in of History History of pri ® ® ® ® ® ® ® ® ® ®

76805 [plus CPT [plus 76805 or 76805 76817 once or or once when symptomatic 76817 76801 76816 can be performed every 3 to 6 3to every weeks beperformed can 76816 76815

76815 76815 76801 [plus CPT [plus 76801 76805 76805 76815 ® ® CPT 76817 76816

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

76815), once when symptomatic starting at 30 weeks; if <30 weeks send to Medical Director Review  For history of pre-term labor, See OB-9.9: History of Spontaneous Pre-Term Delivery/History of PPROM Practice Notes  In circumstances where the individual is deemed to have an increased risk for a fetal abnormality and does not have access to a provider who can perform the more desirable fetal and maternal ultrasound with detailed fetal anatomic examination (CPT® 76811) due to geographic or other constraints, a standard (after first trimester) fetal and maternal ultrasound (CPT® 76805) may be authorized instead.  CPT® 76811 and CPT® 76812 should only be used once per pregnancy unless the mother changes to a new medical caregiver at a new office and there is a new medical indication and/or change in condition. References 1. ACOG Practice Bulletin No.142: Cerclage for the Management of Cervical Insufficiency. Obstet Gynecol. 2014;123(2, PART 1):372-379.Reaffirmed 2019. doi:10.1097/01.aog.0000443276.68274.cc. 2. ACOG Practice Bulletin No. 130: Prediction and Prevention of Preterm Birth. Obstet Gynecol. 2012;120(4):964-973. Reaffirmed 2016. doi:10.1097/AOG.0b013e3182723b1b. 3. ACOG. Practice Bulletin No. 171: Management of Preterm Labor. Obstetrics & Gynecology. 2016;128(4).Reaffirmed 2018. doi:10.1097/aog.0000000000001711. 4. Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstet Gynecol. 2016;128(6):e241-e256. Reaffirmed 2018. doi:10.1097/AOG.0000000000001815. 5. Society for Maternal-Fetal Medicine. Progesterone and preterm birth prevention: translating clinical trials data into clinical practice. Am J Obstet Gynecol. 2012;206(5):376- 386.doi:10.1016/j.ajog.2012.03.010 6. Esplin MS, Elovitz MA, Iams JD, et al. Predictive Accuracy of Serial Transvaginal Cervical Lengths and Quantitative Vaginal Fetal Fibronectin Levels for Spontaneous Preterm Birth Among Nulliparous Women. JAMA. 2017;317(10):1047. doi:10.1001/jama.2017.1373. 7. Mcintosh J, Feltovich H, Berghella V, Manuck T. The role of routine cervical length screening in

selected high- and low-risk women for preterm birth prevention. Society for Maternal-Fetal Medicine (SMFM) Consult Series #40. American Journal of Obstetrics and Gynecology. 2016;215(3). doi:10.1016/j.ajog.2016.04.027. 8. SMFM Statement: Use of 17-alpha hydroxyprogesterone caproate for prevention of recurrent preterm birth. American Journal of Obstetrics and Gynecology. 2020. doi:10.1016/j.ajog.2020.04.001. 9. Blackwell SC, Gyamfi-Bannerman C, Biggio JR Jr, et al. 17-OHPC to Prevent Recurrent Preterm Birth in Singleton Gestations (PROLONG Study): A Multicenter, International, Randomized Double- Blind Trial. Am J Perinatol. 2020;37(2):127–136. doi:10.1055/s-0039-3400227

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-19: No Fetal Heart Tones/Decreased Fetal Movement OB-19.1: No Fetal Heart Tones 77 OB-19.2: Decreased Fetal Movement 77

______©2020 eviCore healthcare. All Rights Reserved. Page 76 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______2. 1. Reference (CPT BPP weeks BPP (CPT modified or ultrasound limited following: of the one Report OB-  OB- Obstetrical Ultrasound ©2020       Reaffirmed 2018. doi:10.1097/AOG.0000000000001815. Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstet Gynecol. 2016;128(6):e241 Reaffirmed 2019. doi:10.1097/01.AOG.0000451759.90082.7b. Practice Bulletin No. 145: Antepartum Fetal Surveillance. Obstet Gynecol. 2014;124(1):182- held or Doppler device Doppler held or fetal ultrasound, considering to Prior CPT CPT CPT Report symptoms. Dopplerheld are device, butnow vaginal bleeding, or etc.) heart fetal if had tones heart tones imagingUltrasound supported, is <12weeks if in gestation, thesetting fetalof absent imagingUltrasound supported is ≥12weeks if fetal anatomic scan CPT anatomic scan fetal s using device. using tones Dopplera hand-held 19.2: Decreased 19.1: eviCore healthcare. All Rights Reserved. CPT complete ultrasound has notyet beenperformed; or CPT ® ® ® The following is supported during the second the during supported is following The

76805 (plus CPT76805 (plus 76815 for limited ultrasound or 76816 s one No Fetal Heart Tones ® ®

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB-20: Fetal Growth Problems (FGR and Macrosomia) OB-20.1: Fetal Growth Restriction Current Pregnancy 79 OB-20.2: Macrosomia – Large for Dates Current Pregnancy 80

OB -20.1: Fetal Growth Restriction Current Pregnancy  The ACOG definition of Fetal Growth Restriction (FGR): Estimated or actual weight of the fetus ≤10th percentile for gestational age. “Abdominal Circumference ≤10th percentile” also defines FGR. For Suspected FGR:  If there a ≥3 week difference in fundal height and gestational age report one of the following: CPT® 76805 (plus CPT® 76810 for each additional fetus) if a complete ultrasound has not yet been performed during this pregnancy or CPT® 76816 if a complete ultrasound was performed previously  One follow-up ultrasound (CPT® 76816) can be performed in 2 to 4 weeks following the initial ultrasound to confirm FGR  For clinical situations that have a higher probability of FGR such as maternal hypertension, maternal diabetes, previous stillbirth, etc. See OB-9: High Risk Pregnancy, or the specific guidelines for these clinical entities for guidance regarding follow-up ultrasounds to assess fetal growth For Known FGR:  Detailed Fetal Anatomic Scan (CPT® 76811) upon diagnosis if not already performed  Follow up ultrasound (CPT® 76816) may be performed every 2 to 4 weeks starting at 23 weeks if complete ultrasound previously performed. If <23 weeks, send to Medical Director Review.  Between 23 to 26 weeks, a limited ultrasound/modified BPP (CPT®76815) can be considered weekly.  Starting at 26 weeks, BPP (CPT® 76818 or CPT® 76819) or a modified BPP (CPT® 76815) may be performed weekly.  Starting at 23 weeks, umbilical artery (UA) Doppler (CPT® 76820) may be performed every 1-2 weeks  If severe FGR (EFW <3%, AC <3%), or with decreased end-diastolic velocity (S/D ratio, >95th percentile for gestational age) or with confirmed oligohydramnios, then umbilical ® artery (UA) Doppler (CPT 76820) may be performed weekly  With absent or reversed end diastolic flow more frequent BPPs (CPT® 76818 or CPT® 76819) and umbilical artery (UA) Doppler (CPT® 76820) may be considered (up to 2-3 times per week). If requested more frequently, or in all cases with reversed end diastolic flow, send to Medical Director Review. Practice Notes  An abnormal umbilical artery Doppler is defined as a PI, RI, or S/D ratio greater than the 95th percentile for gestational age or an absent or reversed end-diastolic velocity (AEDV or REDV).  Those with REDV are usually hospitalized for closer surveillance and delivery planning.  SMFM suggest that ductus venosus, middle cerebral artery, or uterine artery Doppler use for routine clinical management of early- or late-onset FGR is not recommended (GRADE 2A). In circumstances where CPT® 76811 cannot be performed See OB-1.3: Ultrasound Code Selection

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

______©2020 eviCore healthcare. All Rights Reserved. Page 79 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com .ACOG 6. .ACOG 8. 7. 5. 4. 3. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______2. 1. References  Notes Practice   OB- Obstetrical Ultrasound ©2020      doi:10.1097/aog.0000000000003607. doi:10.1016/j.ajog.2012.01.022 restriction. Berkley E, Chauhan SP, Abuhamad A. Doppler assessment of the fetus with intrauterine growth Reaffirmed 2018. doi:10.1097/AOG.0000000000001815. Med second American Institute of Ultrasound in Medicine. AIUM practice guideline for the performance of Reaffirmed 2019. doi:10.1097/01.AOG.0000451759.90082.7b. Practice Bulletin No. 145: Antepartum Fetal Surveillance. Obstet Gynecol. 2014;124(1):182 - 2014;123(5):1057 Copel JA, Bahtiyar MO. A Practical Approach to Fetal Growth Restriction. #52: Diagnosis and Management of Fetal Growth Restriction. 2020 Martins JG, Biggio, JR, Abuhamad, A. Society for Maternal 2019;133(2):e97- ACOG Practice Bulletin No. 204: Fetal Growth Restriction. Obstetrics & Gynecology derived by ultrasonography by derived estimates as beas may predictive of macrosomia estimates clinical shown that Ultrasound See - (non 4500grams or (DM) grams 4000 than greater of weight fetal Estimated macrosomia: of definition The ACOG age, If noother high indication risk present, oneCPT are other high indications. risk Repeat generally imaging is notnecessary unless neededto for delivery plan there or if See ≥ At gestationbefore 30weeks I 20.2: Macrosomia – n a low risk n alow risk pregnancy, is ultrasound generally not indicated weight toestimate fetal eviCore healthcare. All Rights Reserved. icine CPT CPT macrosomia (obesity, DM, See etc.) scan has not has scan yet beenperformed or OB 23 weeks gestation, a gestation, there is if 23 weeks Additional imagingAdditional are usually recommendations ofthe cause by guided thefetal OB may may Practice Bulletin No. 175: Ultrasound in Pregnancy. Obstet Gynecol. Practice Bulletin No. - and - 2019; 38:3093 27.1: Unequal andDates FundalSize -27.1: ® ® A

: Prior Pregnancy with Macrosomia with Pregnancy Prior : 9.4.1 – 76816 if acomplete76816 if ultrasound CPT 76805 [plus report report merican Journal of Obstetrics and Gynecology. 2012; third is imprecise in predicting fetal macrosomia. Prospective studies have studies Prospective macrosomia. fetal in predicting is imprecise e109. doi:10.1097/AOG.0000000000003070. - - trimester diagnostic obstetric ultrasound examinations 1069. doi:10.1097/aog.0000000000000232. Imaging one For Known Macrosomia Macrosomia Known For - of the following: 3100.

Guidelines 216: Fetal Macrosomia. Obstet Gynecol. 20; ® For Suspected Macrosomia: Suspected For Large for Dates Current Pregnancy 76810

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB-21: Placental and Cord Abnormalities OB-21.1: Single Umbilical Artery (Two Vessel Cord) 82 OB-21.2: Persistent Right Umbilical Vein (PRUV) 82 OB-21.3: Placental/Cord Abnormalities 83 OB-21.3.1: Placental/Cord Abnormalities 83 OB-21.3.2: Other Placental/Cord Abnormalities 83 OB-21.4: Subchorionic Hematoma/Hemorrhage (Placental Hematoma) 84 OB-21.5: Suspected Abruptio Placentae 85 OB-21.6: Previa (Placenta Previa and Vasa Previa) 85 OB-21.6.1: Placenta Previa 85 OB-21.6.2: Vasa Previa 86 OB-21.7: Placenta Accreta Spectrum (Accreta, Increta, Percreta) 87 OB-21.7.1: Suspected 87 OB-21.7.2: Known 87

OB -21.1: Single Umbilical Artery (Two Vessel Cord) If a single umbilical artery is found on initial imaging:  Detailed anatomic ultrasound at 16 weeks or greater CPT® 76811 CPT® 76825 and/or  Fetal echocardiogram (usually done >16 weeks) CPT® 76827 and/or CPT® 93325  Follow-up ultrasound to evaluate fetal growth at ≥28 weeks and then every 3 to 6 weeks if more than one clinical high- CPT® 76816 risk factors are documented CPT® 76818 or  Weekly BPP or modified BPP starting at 36 weeks CPT® 76819 (BPP) or modified BPP CPT® 76815 Practice Note  In circumstances where the individual is deemed to have an increased risk for a fetal abnormality and does not have access to a provider who can perform the more desirable fetal and maternal ultrasound with detailed fetal anatomic examination (CPT® 76811) due to geographic or other constraints, a standard (after first trimester) fetal and maternal ultrasound (CPT® 76805) may be authorized instead.  CPT® 76811 and CPT® 76812 should only be used once per pregnancy unless the mother changes to a new medical caregiver at a new office and there is a new medical indication and/or change in condition.

OB-21.2: Persistent Right Umbilical Vein (PRUV) If a PRUV is found on initial imaging:  Detailed anatomic ultrasound at 16 weeks or greater CPT® 76811 CPT® 76825 and/or  Fetal echocardiogram (usually done >16 weeks) CPT® 76827 and/or CPT® 93325  Follow-up ultrasound to evaluate fetal growth at ≥28 weeks and then every 3 to 6 weeks if more than one clinical high- CPT® 76816 risk factors are documented CPT® 76818 or  Weekly BPP or modified BPP starting at 32 weeks CPT® 76819 (BPP) or modified BPP CPT® 76815

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB -21.3: Placental/Cord Abnormalities OB-21.3.1: Placental/Cord Abnormalities Circumvallate Placenta Placental hemangioma Succenturiate placenta or accessory lobe Hypo/Hyper-coiled Umbilical Cord Marginal Cord Insertion Umbilical cord cyst Velamentous Cord Insertion  Fetal anatomic scan can be performed after 16 weeks (CPT® 76805/CPT® 76811) and/or CPT® 93976 (limited duplex scan of arterial and venous)  Ultrasound CPT® 76817 may be indicated to evaluate the placenta and/or cord in relation to the cervix  Ultrasound (CPT® 76816) and/or CPT® 93976 (limited duplex scan) every 3-6 weeks starting at 28 weeks until delivery  Weekly BPP or modified BPP (CPT® 76818/CPT® 76819 or CPT® 76815) starting at 32 weeks Practice Note  Hypo/Hyper-coiled umbilical cord - Several studies have reported an increased frequency of adverse pregnancy outcome, including congenital anomalies, growth restriction, fetal heart rate abnormalities, preterm birth, and intrauterine death in pregnancies with both hypocoiled and hypercoiled umbilical cord  Amniotic bands may occur due to uterine synechiae (intrauterine adhesions), residual gestation sac of a demised twin, fibrin strands s/p bleeding, chorioamniotic separation or may be noted with a circumvallate placenta. In general, they are

benign entities and are not associated with adverse pregnancy outcome, as such, do not need to be followed. Most providers will want at least one follow-up US after it is identified (typically at the time of fetal anatomy scan) to ensure that the finding is indeed benign and the band has not increased in size, nor is it restricting fetal growth or movement. Therefore, one f/u scan in the third trimester may be indicated. (Note – Amniotic Band SYNDROME is a very different entity which is NOT benign, and is associated with very increased risk of fetal anomalies – this would be imaged as in OB-9: High Risk Pregnancy).

OB-21.3.2: Other Placental/Cord Abnormalities Chorioangioma Umbilical cord varix  Detailed fetal anatomic scan can be performed after 16 weeks (CPT® 76811) with or without CPT® 93976 (limited duplex scan)  Ultrasound (CPT® 76816) with or without CPT® 93976 (limited duplex scan) every 3- 6 weeks starting at the time of diagnosis until delivery Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

 Weekly BPP (CPT® 76818 or CPT® 76819) or a modified BPP (CPT® 76815) starting at 32 weeks  Both chorioangioma and UVV can be associated with fetal anemia and/or low output heart failure. As such, MCA Dopplers (CPT® 76821) may be indicated e.g. If turbulence develops within the UVV  If suspected or known hydrops, Fetal ECHO (CPT® 76825, CPT® 76827, CPT® 93325) may be indicated. If fetal hydrops develops then image as per OB-16.1: Alloimmunization/Rh Isoimmunization Practice Note  In circumstances where the individual is deemed to have an increased risk for a fetal abnormality and does not have access to a provider who can perform the more desirable fetal and maternal ultrasound with detailed fetal anatomic examination (CPT® 76811) due to geographic or other constraints, a standard (after first trimester) fetal and maternal ultrasound (CPT® 76805) may be authorized instead.  CPT® 76811 and CPT® 76812 should only be used once per pregnancy unless the mother changes to a new medical caregiver at a new office and there is a new medical indication and/or change in condition.

OB-21.4: Subchorionic Hematoma/Hemorrhage (Placental Hematoma) Subchorionic Hematoma/Hemorrhage (Placental Hematoma)  Ultrasound can be performed for follow-up of a known subchorionic hematoma or placental hematoma  CPT® 76815 and/or CPT® 76817 if the last ultrasound was performed greater than seven days ago or  CPT® 76816 and/or CPT® 76817 if a complete ultrasound scan was performed ≥2 weeks ago

 Imaging may be repeated earlier than seven days if there are new or worsening symptoms such as an increasing amount of vaginal bleeding or increasing cramping or pain.  No further imaging is needed if the follow-up ultrasound shows that the hemorrhage has resolved.  If pregnancy is in second or third trimester follow OB-21.5: Suspected Abruptio Placentae

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB -21.5: Suspected Abruptio Placentae Suspected Abruptio Placentae Second and Third Trimesters  For suspected abruptio placentae: CPT® 76805 [plus CPT® 76810 for each additional fetus] and/or CPT® 76817 if a complete fetal anatomic scan has not yet been performed during this pregnancy, and/or CPT® 93976 (limited duplex scan) CPT® 76815 for limited ultrasound and/or CPT® 76817, or CPT® 76816 if a complete ultrasound scan was done previously, and/or CPT® 76817 Vaginal bleeding with +KB (Kleihauer-Betke) – feto-maternal hemorrhage – at risk for fetal anemia and hydrops CPT® 76821 may be indicated, send to Medical Director Review  Ultrasound is appropriate to follow-up a known abruption: CPT® 76815 or CPT® 76816 if a complete ultrasound was done previously and/or CPT® 76817. The number and frequency of follow-up ultrasounds will depend on the degree of abruption and the presence or absence of ongoing signs and symptoms

OB-21.6: Previa (Placenta Previa and Vasa Previa) OB-21.6.1: Placenta Previa Placenta Previa Second and Third Trimesters  For suspected placenta previa one of the following ultrasound can be performed:  CPT® 76805 [plus CPT® 76810 for each additional fetus] and/or CPT® 76817 if a complete fetal anatomic scan has not yet been performed during this pregnancy and/or CPT® 93976 (limited duplex scan) or  CPT® 76815 for limited ultrasound and/or CPT® 76817 and/or CPT® 93976 (limited duplex scan) or ® ®

 CPT 76816 if a complete ultrasound was done previously and/or CPT 76817 for a transvaginal ultrasound and/or CPT® 93976 (limited duplex scan)  For known placenta previa:  One routine follow-up ultrasound can be performed in the 3rd trimester (CPT® 76815 or CPT® 76816 and/or CPT® 76817)  If placenta previa is still present, one follow-up ultrasound (CPT® 76815 or CPT® 76816 and/or CPT® 76817) can be performed in 3-4 weeks  If persistent placenta previa, BPP (CPT® 76818 or CPT® 76819) or a modified BPP (CPT® 76815) weekly, starting at 32 weeks  Follow-up ultrasound can be performed at any time if bleeding occurs BPP (CPT® 76818 or CPT® 76819) or CPT® 76815 or CPT® 76816 if a complete ultrasound was done previously and/or CPT® 76817) Low Lying Placenta  Ultrasound (CPT® 76815 and/or CPT® 76817) is supported between 28-32 weeks one time to check the placental location. Further requests will be forwarded to Medical Director Review Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

Practice Note  For pregnancies beyond 16 weeks, if the placental edge is ≥2 cm away from the internal os, the placental location should be reported as normal.  If the placental edge is <2 cm from the internal os but not covering the internal os, it should be labeled as low lying.  If the placental edge covers the internal cervical os, the placenta should be labeled as a placenta previa.  At the follow-up examination at 28-32 weeks, if the placental edge is still <2cm from the internal os (low lying) or covering the cervical os (placenta previa), follow-up transvaginal imaging at 36 weeks gestation is recommended.”  “There is no evidence to guide the optimal time of subsequent imaging in pregnancies thought to have placenta previa. In stable patients it is reasonable to perform a follow-up ultrasonogram at approximately 32 weeks of gestation. This allows adequate time for “resolution” of low-lying placentas and avoids potentially unnecessary studies. It may be worthwhile to perform an additional study at 36 weeks of gestation (if the previa persists) to determine the optimal route and timing of delivery. There is no clear benefit from more frequent ultrasonograms (eg, every 4 weeks) in stable cases.”21 OB-21.6.2: Vasa Previa  Vasa previa occurs when fetal blood vessels that are unprotected by the umbilical cord or placenta run through the amniotic membranes and cross over the internal cervical os. If a Vasa Previa is found on initial imaging:  Detailed anatomic ultrasound at ≥16 weeks CPT® 76811  Follow-up growth ultrasound every 3-6 weeks CPT® 76816 starting at ≥23 weeks

 Once vasa previa is confirmed cervical length CPT® 76817 and CPT® 76816 or screening every 2 to 4 weeks starting at 28 weeks CPT® 76815 If earlier request send to Medical Director Review CPT® 76818 or  BPP or modified BPP weekly starting at 32 weeks CPT® 76819 (BPP) or CPT® 76815

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB -21.7: Placenta Accreta Spectrum (Accreta, Increta, Percreta)  See PV-15.2: Placenta Accreta/Placenta Accreta Spectrum/Placenta Percreta OB-21.7.1: Suspected  For suspected placenta accreta:  CPT® 76811 or CPT® 76805 and/or CPT® 76817 if a complete fetal anatomic scan has not yet been performed and/or CPT® 93976 (limited duplex scan) or  CPT® 76816 (if a complete ultrasound was done previously) or CPT® 76815 and/or CPT® 76817 and/or CPT® 93976 (limited duplex scan), or  If the ultrasound is inconclusive or equivocal then MRI Pelvis without contrast (CPT® 72195) may be indicated OB-21.7.2: Known  For known placenta accreta/percreta:  Follow up growth ultrasounds can be performed every 2 to 4 weeks (CPT® 76816 if a complete ultrasound was done previously and/or CPT® 76817)  BPP (CPT® 76818 or CPT® 76819) or a modified BPP (CPT® 76815) weekly, starting at 32 weeks or sooner if indicated (other high-risk concerns)  Follow-up ultrasound can be performed at any time if bleeding occurs (CPT® 76815 and/or CPT® 76817)  Medical Director can approve MRI Pelvis without contrast (CPT® 72195) if the ultrasound is indeterminate or advanced imaging is needed for surgical planning. MRI Pelvis without contrast (CPT® 72195) is the appropriate code if only placenta or maternal pelvis is imaged without fetal imaging

References 1. ACOG Committee Opinion No. 723. Guidelines for Diagnostic Imaging During Pregnancy and Lactation Obstetrics & Gynecology. 2017 Oct;130(4):933-934. doi: 10.1097/AOG.0000000000002350. 2. AIUM Practice Parameter for the Performance of Limited Obstetric Ultrasound Examinations by Advanced Clinical Providers. Journal of Ultrasound in Medicine. 2018;37(7):1587-1596. doi:10.1002/jum.14677. 3. Lide B, Lindsley W, Foster MJ, Hale R, Haeri S. Intrahepatic Persistent Right Umbilical Vein and Associated Outcomes. Journal of Ultrasound in Medicine. 2016;35(1):1-5. doi:10.7863/ultra.15.01008. 4. Zangen R, Boldes R, Yaffe H, Schwed P, Weiner Z. Umbilical cord cysts in the second and third trimesters: significance and prenatal approach. Ultrasound in Obstetrics and Gynecology. 2010;36(3):296-301. doi:10.1002/uog.7576. 5. Predanic M, Perni SC, Chasen ST, et.al. Ultrasound evaluation of abnormal umbilical cord coiling in second trimester of gestation in association with adverse pregnancy outcome. Am J Obstet Gynecol. 2005 Aug;193(2):387-94. doi:10.1016/j.ajog.2004.12.092. 6. Laat MWMD, Franx A, Bots ML, Visser GHA, Nikkels PGJ. Umbilical Coiling Index in Normal and Complicated Pregnancies. Obstetrics & Gynecology. 2006;107(5):1049-1055. doi:10.1097/01.aog.0000209197.84185.15. 7. Mckinney J, Rac MW, Gandhi M. Society for Maternal-Fetal Medicine (SMFM) Fetal Anomalies Consult Series #2: December 2019. https://doi.org/10.1016/j.ajog.2019.09. 8. Weissmann-Brenner A, Simchen MJ, Moran O, Kassif E, Achiron R, Zalel Y. Isolated fetal umbilical vein varix-prenatal sonographic diagnosis and suggested management. Prenatal Diagnosis. 2009;29(3):229-233. doi:10.1002/pd.2219. Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

9. Zalel Y, Lehavi O, Heifetz S, et al. Varix of the fetal intra-abdominal umbilical vein: prenatal sonographic diagnosis and suggested in utero management. Ultrasound in Obstetrics and Gynecology. 2000;16(5):476-478. doi:10.1046/j.1469-0705.2000.00283.x. 10. Lee SW, Kim MY, Kim JE, Chung JH, Lee HJ, Yoon JY. Clinical characteristics and outcomes of antenatal fetal intra-abdominal umbilical vein varix detection. Obstetrics & Gynecology Science. 2014;57(3):181. doi:10.5468/ogs.2014.57.3.181. 11. ACOG Committee Opinion No. 764 Summary: Medically Indicated Late-Preterm and Early-Term Deliveries. Obstet Gynecol. 2019;133(2):400-403. doi:10.1097/AOG.0000000000003084. 12. Tuuli MG, Norman SM, Odibo AO, Macones GA, Cahill AG. Perinatal Outcomes in Women With Subchorionic Hematoma. Obstetrics & Gynecology. 2011;117(5):1205-1212. doi:10.1097/aog.0b013e31821568de . 13. Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period. American Journal of Obstetrics and Gynecology. 2018;218(1). doi:10.1016/j.ajog.2017.10.019. 14. Heller HT, Mullen KM, Gordon RW, Reiss RE, Benson CB. Outcomes of pregnancies with a low-lying placenta diagnosed on second-trimester sonography. J Ultrasound Med. 2014 Apr;33(4):691-6. doi: 10.7863/ultra.33.4.691. 15. Silver RM. Abnormal Placentation Placenta Previa, Vasa Previa, and Placenta Accreta. Obstetrics & Gynecology. 2015;126(3):654-668. doi:10.1097/aog.0000000000001005. 16. Sinkey RG, Odibo AO, Dashe JS. Society for Maternal-Fetal Medicine (SMFM) #37: Diagnosis and management of vasa previa. American Journal of Obstetrics and Gynecology. 2015;213(5):615-619. doi:10.1016/j.ajog.2015.08.031. 17. Cahill AG, Beigi R, Heine P, Silver RM, Wax JR. Placenta Accreta Spectrum. Obstetric Care Consensus No. 7. Obstetrics & Gynecology. 2018;132(6):e259-e275. doi:10.1097/aog.0000000000002983. 18. Kilcoyne A, Shenoy-Bhangle AS, Roberts DJ, Sisodia RC, Gervais DA, Lee SI. MRI of Placenta Accreta, Placenta Increta, and Placenta Percreta: Pearls and Pitfalls. American Journal of Roentgenology. 2017;208(1):214-221. doi:10.2214/ajr.16.16281. 19. SMFM Coding Committee White Paper: Coding for Placenta Accreta Spectrum. 20. Calì G, Giambanco L, Puccio G, Forlani F. Morbidly adherent placenta: evaluation of ultrasound diagnostic criteria and differentiation of placenta accreta from percreta. Ultrasound in Obstetrics & Gynecology. 2013;41(4):406-412. doi:10.1002/uog.12385. 21. Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. American Journal of Obstetrics and Gynecology. 2018;218(1):75-87. doi:10.1016/j.ajog.2017.05.067.

22. Mari G, Norton ME, Stone J, et al. Society for Maternal-Fetal Medicine (SMFM) Clinical Guideline #8: The fetus at risk for anemia–diagnosis and management. American Journal of Obstetrics and Gynecology. 2015;212(6):697-710. doi:10.1016/j.ajog.2015.01.059. Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-22: Late-term/Post-term Pregnancy OB-22.1: Late-term/Post-term Pregnancy 90

______©2020 eviCore healthcare. All Rights Reserved. Page 89 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com clinical utility predicting in FGR, SGA birth, and perinatal mor 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______2. 1. Reference beuseful. to found post In Note Practice OB- Obstetrical Ultrasound ©2020  Gynecology. 2020. doi:10.1016/j.ajog.2020.05.010. #52: Diagnosis and Management of Fetal Growth Restriction. American Journal of Obstetrics and Martins JG, Biggio JR, Abuhamad A. Society for Maternal 2014;124(2, PART 1):390- Practice Bulletin No. 146: Management of Late-Term and Postterm Pregnancies. Obstet Gynecol.  at is supported Ultrasound  22.1: Late-

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93976) has not been not has 93976) www.eviCore.com CPT Page 90of109 ® 76815 . V3 .0

Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB-23: Preterm/Prelabor Rupture of Membranes OB-23.1: Current Preterm/Prelabor Rupture of Membranes (PPROM) 92 OB-23.2: Current Prelabor Rupture of Membranes (PROM) 92

See OB-17: Amniotic Fluid Abnormalities/Oligohydramnios/Polyhydramnios

______©2020 eviCore healthcare. All Rights Reserved. Page 91 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com .ACOG 3. .ACOG 2. 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______1. References  OB-  OB- Obstetrical Ultrasound ©2020 February Gynecology 2 ACOG  If ≥   If ≤ 016;128(4):e155 23.2: 23.1: Current Preterm

eviCore healthcare. All Rights Reserved. - - 37 weeks weeks 6/7 36 This will likely result in a hospital admission for delivery for admission in ahospital result likely This will cases inrare Only delivery. until andmonitoring evaluation for admission ahospital This islikely

Practice Bulletin No. Practice Bulletin No. 171: Management of Preterm Labor. Obstetrics & Gynecology Practice Bulletin No.130: Prediction and Prevention of Preterm Birth.

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2016. doi:10.1097/AOG.0b013e3182723b1b. R eview. eview. 8924 8924 Obstetrics & Gynecology.

Obstetrics & Obstetrics

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB-24: Previous C-section or History of Uterine Scar OB-24.1: Previous C-section or History of Uterine Scar 94

OB -24.1: Previous C-section or History of Uterine Scar

Previous Cesarean section and/or uterine scar  Ultrasound in the first trimester may be indicated to establish dates. Report one of the following: CPT® 76801 [plus CPT® 76802 for each additional fetus] if a complete ultrasound has not yet been performed, and/or CPT® 76817 if <14 weeks, or CPT® 76815 and/or CPT® 76817 for dating if ≥14 weeks and <16 weeks  Fetal anatomic scan CPT® 76805 ≥16 weeks. (if requested earlier send to Medical Director Review)  One growth scan (CPT® 76816) in the early third trimester (between 28-32 weeks) and one growth scan (CPT® 76816) for delivery planning later in third trimester (between 36- 38 weeks)  Transvaginal ultrasound, CPT® 76817 may be indicated for poor visualization of the lower uterine segment or if uterine wall thinning (dehiscence) is suspected. References 1. Gyamfi-Bannerman C, Gilbert S, Landon MB, et al. Risk of Uterine Rupture and Placenta Accreta With Prior Uterine Surgery Outside of the Lower Segment. Obstetrics & Gynecology. 2012;120(6):1332-1337. doi:10.1097/aog.0b013e318273695b. 2. ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology. 2019;133(2):110-127. doi:10.1097/aog.0000000000003078. 3. Hamar BD, Levine D, Katz NL, Lim K-H. Expectant Management of Uterine Dehiscence in the Second Trimester of Pregnancy. Obstetrics & Gynecology. 2003;102(Supplement):1139-1142. doi:10.1097/00006250-200311001-00006. 4. Oyelese Y, Tchabo J-G, Chapin B, Nair A, Hanson P, Mclaren R. Conservative Management of Uterine Rupture Diagnosed Prenatally on the Basis of Sonography. Journal of Ultrasound in Medicine. 2003;22(9):977-980. doi:10.7863/jum.2003.22.9.977.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-25: Termination of Pregnancy – Imaging OB-25.1: Imaging for Planned Pregnancy Termination 96

OB -25.1: Imaging for Planned Pregnancy Termination  For a planned pregnancy termination, ultrasound can be performed to determine intrauterine pregnancy and gestational age.  One complete ultrasound (CPT® 76801) and/or one transvaginal ultrasound (CPT® 76817), if <14 weeks, or  CPT® 76815 and/or CPT® 76817, or  If ≥14 weeks, CPT® 76805 may be indicated, (there may be State mandated imaging prior to termination) send to Medical Director Review.

Practice Note  In general, most ultrasound requests are approvable for planned pregnancy termination regardless of clinical information provided. Imaging may be indicated to confirm EGA, placenta location, and/or fetal anomalies.

References 1. ACOG Practice Bulletin No.143. Medical management of first-trimester abortion. Obstetrics & Gynecology. 2014;123(3):676-692.Reaffirmed 2016. doi:10.1097/01.aog.0000444454.67279.7d. 2. ACOG Practice Bulletin No. 135. Second-trimester abortion. Obstetrics & Gynecology. 2013;121(6):1394-1406. Reaffirmed 2017. doi:10.1097/01.aog.0000431056.79334.cc.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-26: Trauma OB-26.1: Trauma – Imaging 98

OB -26.1: Trauma – Imaging Prior to 13 weeks:  Blunt trauma in the first trimester (prior to 13 weeks) generally does not cause pregnancy loss with the exception of profound hypotension:  No imaging is indicated unless there is cramping and/or bleeding. Between 13-20 weeks gestation:  CPT® 76801 and/or CPT® 76817 when complete ultrasound has not yet been performed, if <14 weeks or  CPT® 76815 and/or CPT® 76817 or  CPT® 76805 (plus CPT® 76810 for each additional fetus) if ≥14 weeks, when complete fetal anatomic scan CPT® 76805 and/or CPT® 76817 has not yet been performed After 20 weeks:  CPT® 76805 (plus CPT® 76810 for each additional fetus) when complete fetal anatomic scan (CPT® 76805) has not yet been performed, or  CPT® 76815 and/or CPT® 76817 or  CPT® 76816  Additionally, starting at 26 weeks, BPP (CPT® 76818 or CPT® 76819) or modified BPP (CPT® 76815) can be considered  Vaginal bleeding with +KB (Kleihauer-Betke) (feto-maternal hemorrhage) at risk for fetal anemia and hydrops, CPT® 76821 may be indicated, send to Medical Director Review.  Other advanced imaging may be indicated, send for Medical Director Review References 1. Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic review. American Journal of Obstetrics and Gynecology. 2013;209(1):1-10. doi:10.1016/j.ajog.2013.01.021. 2. Mari G, Norton ME, Stone J, et al. Society for Maternal-Fetal Medicine (SMFM) Clinical Guideline #8: The fetus at risk for anemia–diagnosis and management. American Journal of Obstetrics and Gynecology. 2015;212(6):697-710. doi:10.1016/j.ajog.2015.01.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-27: Unequal Fundal Size and Dates OB-27.1: Unequal Fundal Size and Dates 100

OB -27.1: Unequal Fundal Size and Dates Unequal fundal size is defined as a discrepancy between weeks of gestational age and fundal height measurement of ≥3 cm and gestational age at ≥23 weeks gestation  One ultrasound can be performed (CPT® 76805) if complete fetal anatomic scan is planned and has not been performed or  CPT® 76816 if complete anatomy scan or detailed anatomy ultrasound (CPT® 76805/CPT® 76811) has been done previously  Where fundus cannot be adequately palpated such as in obesity, leiomyomas, multiple gestations, See appropriate chapter References 1. Pay A, Frøen J, Staff A, Jacobsson B, Gjessing H. Prediction of small-for-gestational-age status by symphysis-fundus height: a registry-based population cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. 2016;123(7):1167-1173. doi:10.1111/1471-0528.13727. 2. Pay ASD, Wiik J, Backe B, Jacobsson B, Strandell A, Klovning A. Symphysis-fundus height measurement to predict small-for-gestational-age status at birth: a systematic review. BMC Pregnancy and Childbirth. 2015;15(1). doi:10.1186/s12884-015-0461-z. 3. ACOG Practice Bulletin No. 204: Fetal Growth Restriction. Obstet Gynecol. 2019;133(2):e97-e109. doi:10.1097/AOG.0000000000003070. 4. ACOG Practice Bulletin No. 216: Macrosomia. Obstetrics & Gynecology. 2020;135(1):246-248. doi:10.1097/aog.0000000000003607.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB-28: Procedure Coding Basics for Established Pregnancy OB-28.1: Procedure Coding Basics for Established Pregnancy General Considerations 102 OB-28.2: Required Elements for Complete First Trimester Ultrasound 102 OB-28.3: Required Elements for Second or Third Trimester Fetal Anatomic Evaluation Ultrasound 103 OB-28.4: Required Elements for a Detailed Fetal Anatomic Evaluation Ultrasound 104 OB-28.5: Fetal Nuchal Translucency 105 OB-28.6: Limited and Follow-up Studies 106 OB-28.7: Obstetric Transvaginal Ultrasound 106 OB-28.8: Biophysical Profile (BPP) 107 OB-28.9: Fetal Doppler 107 OB-28.10: Duplex Scan 108 OB-28.11: Fetal Echocardiography 108 OB-28.12: 3D and 4D Rendering 109

OB -28.1: Procedure Coding Basics for Established Pregnancy General Considerations  All obstetric ultrasound studies require permanently recorded images which may be stored on film or in a Picture Archiving and Communication System (PACS). Obstetric ultrasound services may not be billed without image recording.  Ultrasound procedure codes include the preparation of a required final written report which should be included in the patient’s medical record.  Each procedure code has specific required elements which are described in this section.  The report should document the results of the evaluation of each element or the reason any element is non-visualized.  Documentation of less than the required elements requires the billing of the “limited” code for that anatomic region.  Only one (1) limited exam may be billed per encounter.  The use of a hand-held or any Doppler device that does not create a hard-copy output is considered part of the physical examination and is not separately billable.

OB-28.2: Required Elements for Complete First Trimester Ultrasound CPT® Code Guidance  CPT® 76801 and CPT® 76802 (for each additional fetus) can be performed up to and including 13 6/7 weeks gestation and is defined in CPT® as including the following elements:  Number and size of gestational sacs and fetuses  Survey of visible fetal anatomic structures and placental evaluation when possible  Qualitative assessment of amniotic fluid volume/gestational sac shape  Examination of maternal uterus and adnexa  CPT® 76801 and CPT® 76802 should only be reported once per pregnancy/per

practice/facility unless the mother changes to a new medical caregiver at a new practice/facility and there is a new medical indication for ultrasound.  Follow-up studies to CPT® 76801 and CPT® 76802 should be reported as CPT® 76815

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB -28.3: Required Elements for Second or Third Trimester Fetal Anatomic Evaluation Ultrasound CPT® Code Guidance  A complete second or third trimester transabdominal ultrasound (CPT® 76805 and CPT® 76810 for each additional fetus) is defined in CPT® as including the following elements:  Head, face, and neck: Lateral cerebral ventricles; Choroid plexus; Midline falx; Cavum septi pellucidi; Cerebellum; Cistern magna; Upper lip: A measurement of the nuchal fold may be helpful during a specific age interval to assess the risk of aneuploidy  Chest/Heart: Four-chamber view; Left and Right ventricular outflow tracts  Abdomen: Stomach (presence, size, and situs); Kidneys; Urinary bladder; Umbilical cord insertion site into the fetal abdomen and number of vessels  Spine: Cervical, thoracic, lumbar, and sacral spine  Extremities: Legs and arms  Genitalia: (In multiple gestations and when medically indicated)  Placenta: Location; Relationship to internal os; Appearance; Placental cord insertion (when possible) and overall Standard evaluation  Fetal number and Presentation  Qualitative or semi-qualitative estimate of amniotic fluid  Maternal anatomy: Cervix (transvaginal if cervical length is ≤3.6 cm), Uterus, and Adnexa  Fetal Biometry: Biparietal diameter, Head circumference, Femur length, Abdominal circumference, and Fetal weight estimate.  CPT® 76805 and CPT® 76810 should only be used once per pregnancy per practice/facility unless the mother changes to a new medical caregiver at a new practice/facility and there is a new medical indication for ultrasound.  Follow-up studies to CPT® 76805/CPT® 76810 should be coded as CPT® 76815 or CPT® 76816.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

OB -28.4: Required Elements for a Detailed Fetal Anatomic Evaluation Ultrasound CPT® Code Guidance  Detailed fetal anatomy scan (CPT® 76811 and CPT® 76812 for each additional fetus) is generally performed by those with special skills to perform this study, such as Maternal Fetal Medicine specialists (Perinatologists), or Radiologists (with advanced training in fetal imaging).  CPT® 76811 and CPT® 76812 are defined in CPT® as including all of the requirements listed for CPT® 76805 and CPT® 76810. In addition, the report must document detailed anatomic evaluation of the following elements:  Head, face, and neck: 3rd and 4th ventricles; Lateral ventricles; Cerebellar lobes, vermis, and cisterna magna; Corpus callosum; Integrity and shape of cranial vault; Brain parenchyma; Neck; Profile; Coronal face (nose/lips/lenses); Palate, maxilla, mandible, and tongue; Ear position and size; Orbits  Chest/Heart: Aortic arch; Superior and inferior vena cava; 3-vessel view; 3-vessel and trachea view; Lungs; Integrity of diaphragm; Ribs  Abdomen: Small and large bowel; Adrenal glands; Gallbladder; Liver; Renal arteries; Spleen; Integrity of abdominal wall  Spine: Integrity of spine and overlying soft tissue; Shape and curvature  Extremities: Number: architecture and position; Hands; Feet; Digits: number and position  Genitalia: Gender  Placenta: Masses; Placental cord insertion; Accessory/succenturiate lobe with location of connecting vascular supply to primary placenta  Biometry: Cerebellum; Inner and outer orbital diameters; Nuchal thickness (16 to 20 wk); Nasal bone measurement (15 to 22 wk); Humerus; Ulna/radius; Tibia/fibula  Maternal Anatomy: Cervix (transvaginal if cervical length is ≤3.6cm); Uterus; Adnexa  CPT® 76811 and CPT® 76812 should only be used once per pregnancy per practice/ facility unless the mother changes to a new medical caregiver at a new facility and there is a new medical indication for ultrasound.  Follow-up studies to CPT® 76811/CPT® 76812 should be coded as CPT® 76815 or CPT® 76816.  In circumstances where the individual is deemed to have an increased risk for a fetal abnormality and does not have access to a provider who can perform the more desirable fetal and maternal ultrasound with detailed fetal anatomic examination (CPT® 76811) due to geographic or other constraints, a standard (after first trimester) fetal and maternal ultrasound (CPT® 76805) may be authorized instead.

Obstetrical Ultrasound Imaging Imaging Ultrasound Obstetrical

______©2020 eviCore healthcare. All Rights Reserved. Page 104 of 109 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______ Note Practice OB-28 Obstetrical Ultrasound ©2020         the of elements Required 76813/CPT screening (CPTscreening notbeshould routinely done whenever anultrasound for nuchal translucency (CPT of The use (NTQR). Program Review The sonographer performing aneuploidy. An NTmm ≥3 Nuchal Abnormal Translucency (≥3 anincreased Fetal risk scan mm)for suggests  (translucent)of theclear atthe ofthe space back neck fetal CPT indication, then theCPT credentialed Foundation byMedicine Fetal Translucency or theMaternal Nuchal Quality fetuses abdominal diaphragmaticdefects, defects, wall and hernia, syndromesgenetic euploid in

eviCore healthcare. All Rights Reserved. between the outer edge of the nuchal skin and the amnion amnion the nuchal the and skin edgeof outer the between differentiation for allows movement embryonic andspontaneous position neutral nuchal translucency nuchal translucency M the of Observation activity fetalcardiac of Observation - crown Fetal .5: Fetal Nuchal Translucency The first trimesterThe first screening gestational gestational age (range 104/7to14 weeks) performed thecrown rump if ® easurement of the largest distance between the inner borders of the fetal of the borders inner the between distance largest of the easurement

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Obstetrical Ultrasound Imaging   400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918- ______ Notes Practice OB-28   Note Practice OB-28 Obstetrical Ultrasound ©2020      (GRADE 2A) If BPP ≤6, repeat BPP in in BPP repeat ≤6, BPP If weeks). (23 viability to doneprior be shouldnot but cases HR certain in sooner beutilized may modified BPP However, gestation. weeks ≥ not until present are breathing, as BPP,such of the components all Typically use for routine clinical management of early SMFM suggest that ductus venosus, middle cerebral artery, or uterine artery Doppler CPT evaluated: are parameters Thefollowing death. fetal of risk the ultimately and, asphyxia fetal of absence or the presence predict designedto The BPP is   CPT   CPT BPP CPT CPT

eviCore healthcare. All Rights Reserved. - (non FHR Reactive 2xcm 2 pocket one least vertical at volume, fluid Amniotic tone Fetal movements body fetal Gross movements breathing Fetal .9 .8: Biophysical Profile (BPP) M (See OB (See acquired or acquired byand non-immune caused hydrops parvovirus B19 infection or any other known isoimmunization/alloimmunization,to Rhesus Twin anemia polycythemia sequence asubstitutePerformed toevaluate for as amniocentesis atrisk for afetus anemia due for knownUtilized FGR; OB Isoimmunization, I typicallyperformed See and knownoligohydramnios ® ts use topredict use preeclampsia,ts andstillbirthis considered investigational. ® ® s, ® ® 76815 ay also be indicated withay be indicated known also 76820 describes Doppler76820 describes artery velocimetry umbilical ofthe notinclude thenon76819 does non76818 includes 76821 describes Doppler76821 describes velocimetry middleartery cerebral ofthe : : performed thanone onmore shouldfetus, bereported separately. - Fetal Doppler Fetal 1 1 : Multiple Multiple : . -11: -11: modified BPP which is NST with AFI with NST is which BPP bill to amodified is used

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eviCore healthcare. All Rights Reserved. obstetrical imaging. obstetrical CPT .11: Fetal Echocardiography .10: Duplex Scan The use ofcolorThe use Doppler (CPT should neverIt should with CPT bebilled service reimbursable. usually alongIt is billed with CPT structure identification,structure during astandard ultrasound procedure, notseparately is ® ® ® ® ® ® 93976

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code accreta or other placental or cord abnormalities). or placental or other accreta

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Obstetrical Ultrasound Imaging Obstetrical Ultrasound Imaging Guidelines V3.0

OB -28.12: 3D and 4D Rendering  There is currently insufficient data to generate appropriateness criteria for the use of 3D and 4D rendering in conjunction with Obstetrical ultrasound imaging. Per ACOG, despite the technical advantages of 3-dimensional ultrasonography, proof of a clinical advantage of 3-dimensional ultrasonography in prenatal diagnosis, in general, is still lacking.

References 1. AIUM-ACR-ACOG-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound Examinations. Journal of Ultrasound in Medicine. 2018;37(11). doi:10.1002/jum.14831. 2. AIUM Practice Parameter for the Performance of Detailed Second‐ and Third‐Trimester Diagnostic Obstetric Ultrasound Examinations. Journal of Ultrasound in Medicine. 2019;38(12):3093-3100. doi:10.1002/jum.15163. 3. Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal Imaging: Executive Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Obstetrics & Gynecology. 2014;123(5):1070-1082. doi:10.1097/aog.0000000000000245 4. ACOG Practice Bulletin No.175. Ultrasound in Pregnancy, 2016; reaffirmed 2018. 5. ACOG Practice Bulletin No. 163: Screening for Fetal Aneuploidy. Obstet Gynecol. 2016;127(5):e123- e137. Reaffirmed 2018. doi:10.1097/AOG.0000000000001406. 6. Society for Maternal and Fetal Medicine (SMFM), coding committee. SMFM Coding Committee White Paper: Billing of 76801 and/or 76813 with cfDNA. October 2017. 7. AIUM Practice Parameter for the Performance of Limited Obstetric Ultrasound Examinations by Advanced Clinical Providers. Journal of Ultrasound in Medicine. 2018;37(7):1587-1596. doi:10.1002/jum.14677 8. ACOG Practice Bulletin No. 145: Antepartum Fetal Surveillance. Obstet Gynecol. 2014;124(1):182- 192. Reaffirmed 2019. doi:10.1097/01.AOG.0000451759 9. Sciscione AC, Hayes EJ. Uterine artery Doppler flow studies in obstetric practice. American Journal

of Obstetrics and Gynecology. 2009;201(2):121-126. doi:10.1016/j.ajog.2009.03.027 10. Fetal growth restriction. ACOG Practice Bulletin No. 204. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133(2). doi:10.1097/aog.0000000000003070. 11. Galan HL. Timing Delivery of the Growth-Restricted Fetus. Seminars in Perinatology. 2011;35(5):262- 269. doi:10.1053/j.semperi.2011.05.009 12. Copel JA, Bahtiyar MO. A Practical Approach to Fetal Growth Restriction. Obstetrics & Gynecology. 2014;123(5):1057-1069. doi:10.1097/aog.0000000000000232. 13. Martins JG, Biggio JR, Abuhamad A. Society for Maternal-Fetal Medicine (SMFM) Consult Series #52: Diagnosis and Management of Fetal Growth Restriction. American Journal of Obstetrics and Gynecology. 2020. doi:10.1016/j.ajog.2020.05.010. 14. AIUM Practice Parameter for the Performance of Fetal Echocardiography. Journal of Ultrasound in Medicine. 2019;39(1). doi:10.1002/jum.15188.

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