ANTEPARTUM FETAL SURVEILLANCE HS-111

Care1st Health Plan Arizona, Inc.

Easy Choice Health Plan

Harmony Health Plan of Illinois

Missouri Care Antepartum Fetal

‘Ohana Health Plan, a plan offered by WellCare Health Surveillance Insurance of Arizona Policy Number: HS-111 OneCare (Care1st Health Plan Arizona, Inc.)

Staywell of Florida Original Effective Date: 6/18/2009

WellCare (Arkansas, Connecticut, Florida, Georgia, Illinois, Kentucky, Louisiana, Mississippi, Nebraska, New Jersey, Revised Date(s): 6/25/2010; 8/2/2011; New York, South Carolina, Tennessee, Texas) 6/7/2012; 12/6/2012; 6/6/2013; 6/5/2014; WellCare Prescription Insurance 5/7/2015; 7/7/2016; 6/1/2017

APPLICATION STATEMENT

The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

DISCLAIMER

The Clinical Coverage Guideline (CCG) is intended to supplement certain standard WellCare benefit plans and aid in administering benefits. Federal and state law, contract language, etc. take precedence over the CCG (e.g., Centers for Medicare and Medicaid Services [CMS] National Coverage Determinations [NCDs], Local Coverage Determinations [LCDs] or other published documents). The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this CCG. Additionally, CCGs relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. Providers are responsible for the treatment and recommendations provided to the member. The application of the CCG is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. All links are current at time of approval by the Medical Policy Committee (MPC) and are subject to change prior to the annual review date. Lines of business (LOB) are subject to change without notice; current LOBs can be found at www.wellcare.com. All guidelines can be found at this site as well but selecting the Provider tab, then “Tools” and “Clinical Guidelines”.

BACKGROUND

Fetal movement assessment occurs when the mother perceives a diminution in fetal movement. The mother counts fetal "kicks" as a means of antepartum fetal surveillance. The optimal number of movements and the ideal duration for counting movements have not been determined; numerous protocols have been reported and appear to be acceptable.

Clinical Coverage Guideline page 1

Original Effective Date: 6/18/2009 - Revised: 6/25/2010, 8/2/2011, 6/7/2012, 12/6/2012, 6/6/2013, 6/5/2014, 5/7/2015, 7/7/2016, 6/1/2017 ANTEPARTUM FETAL SURVEILLANCE HS-111

The is based on the response of the fetal heart rate to uterine contractions. It is believed that fetal oxygenation will be transiently worsened by uterine contractions. In the with suboptimal oxygenation, the resulting intermittent worsening in oxygenation will, in turn, lead to the fetal heart rate pattern of late decelerations. Uterine contractions also may provoke or accentuate a pattern of variable decelerations caused by fetal umbilical cord compression, which in some cases is associated with . The contraction stress test is interpreted by the presence or absence of late fetal heart rate decelerations, which are defined as decelerations that reach their nadir after the peak of the contraction and that usually persist beyond the end of the contraction. The results of the contraction stress test are categorized in the ACOG bulletin as follows:

 Negative. No late or significant variable decelerations.  Positive. Late decelerations following 50 percent or more of contractions (even if the contraction frequency is fewer than three in 10 minutes).  Equivocal-suspicious. Intermittent late decelerations or significant variable decelerations.  Equivocal-hyperstimulatory. Fetal heart rate decelerations that occur in the presence of contractions that are more frequent than every two minutes or last longer than 90 seconds.  Unsatisfactory. Fewer than three contractions in 10 minutes or a tracing that is not interpretable.

Relative contraindications to the contraction stress test usually include conditions that are associated with an increased risk of preterm labor and delivery, uterine rupture or uterine bleeding. Conditions include the following:

 Preterm labor or certain patients at high risk of preterm labor.  Preterm membrane rupture.  History of extensive uterine surgery or classic cesarean delivery.  Known placenta previa.

In the non-stress test, the heart rate of the fetus that is not acidotic or neurologically depressed will temporarily accelerate with fetal movement. Heart rate reactivity is believed to be a good indicator of normal fetal autonomic function. Loss of reactivity is commonly associated with a fetal sleep cycle but may result from any cause of central nervous system depression, including fetal acidosis. Results of non-stress tests are classified as reactive or nonreactive. Various definitions of reactivity have been used. Most commonly, the non-stress test is considered reactive, or normal, if there are two or more fetal heart rate accelerations within a 20-minute period, with or without fetal movement discernible by the woman, according to ACOG. The nonreactive stress test lacks sufficient fetal heart rate accelerations over a 40-minute period. The non-stress test of the neurologically healthy preterm fetus is frequently nonreactive--from 24 to 28 weeks of gestation, up to 50 percent of non-stress tests may not be reactive, and from 28 to 32 weeks of gestation, 15 percent of non-stress tests are not reactive.

The discussed in the ACOG bulletin is a non-stress test plus four observations made by real- time ultrasonography. The five components of the biophysical profile are as follows: (1) non-stress test; (2) fetal breathing movements (one or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutes); (3) fetal movement (three or more discrete body or limb movements within 30 minutes); (4) fetal tone (one or more episodes of extension of a fetal extremity with return to flexion, or opening or closing of a hand; and (5) determination of the volume (a single vertical pocket of amniotic fluid exceeding 2 cm is considered evidence of adequate amniotic fluid). Each of the components is given a score of 2 (normal or present as defined previously) or 0 (abnormal, absent or insufficient). A composite score of 8 or 10 is normal, a score of 6 is equivocal and a score of 4 or less is abnormal. In the presence of oligohydramnios, further evaluation is warranted regardless of the composite score.

Modified Biophysical Profile

During the late second or third trimester, amniotic fluid reflects fetal urine production. Placental dysfunction may cause diminished fetal renal perfusion, which can lead to oligohydramnios. Therefore, assessment of amniotic fluid volume can be used to evaluate long-term uteroplacental function. This led to the development of the modified biophysical profile. The modified biophysical profile combines the non-stress test with the , which is the sum of measurements of the deepest cord-free amniotic fluid pocket in each of the abdominal

Clinical Coverage Guideline page 2

Original Effective Date: 6/18/2009 - Revised: 6/25/2010, 8/2/2011, 6/7/2012, 12/6/2012, 6/6/2013, 6/5/2014, 5/7/2015, 7/7/2016, 6/1/2017 ANTEPARTUM FETAL SURVEILLANCE HS-111

quadrants, as an indicator of long-term function of the placenta. An amniotic fluid index of more than 5 cm is thought to be an adequate volume of amniotic fluid. The modified biophysical profile is considered normal if the non-stress test is reactive and the amniotic fluid index is greater than 5 cm and abnormal if the non-stress test is nonreactive or the amniotic fluid index is 5 cm or less.

Umbilical Artery Doppler Velocimetry

Doppler ultrasonography is used to assess the hemodynamic components of vascular impedence. Umbilical artery Doppler flow velocimetry has been adapted as a fetal surveillance technique because it is believed that flow velocity waveforms in the umbilical artery of with normal growth differ from those of fetuses with growth restriction. The umbilical flow velocity waveform of a normally growing fetus has high-velocity diastolic flow, while in cases of intrauterine growth restriction, the umbilical artery diastolic flow is diminished. With extreme intrauterine growth restriction, the flow may be absent or even reversed. There is a high perinatal mortality rate among such .

POSITION STATEMENT

Applicable To: Medicaid – All Markets

Exclusions

Maternal uterine artery Doppler velocimetry is considered experimental and investigational.

Coverage

A biophysical profile (76818) and the modified biophysical profile (76819) starting at 27 weeks gestation are considered medically necessary for the following indications:

1) Maternal Conditions  Antiphospholipid syndrome;  Poorly-controlled hyperthyroidism; OR,  Hemoglobinopathies with significant anemia-hemoglobin SS, SC, or S-thalassemia; OR,  Cyanotic heart disease; OR,  Systemic lupus erythematosus; OR  Chronic renal disease; OR,  Diabetes mellitus or gestational diabetes on anti-hyperglycemic agents; OR,  Hypertensive disorders

OR

2) -related Conditions  Pre-eclampsia/eclampsia; OR,  Decreased fetal movement; OR,  Oligohydramnios (AFI < 7 cm); OR,  Polyhydramnios (AFI > 24 cm); OR,  Intrauterine growth restriction (EFW < 10th percentile growth); OR,  Post-term pregnancy (greater than 41 weeks gestation; OR,  Moderate to severe isoimmunization; OR,  Previous fetal demise (unexplained or untreated recurrent risk); OR,  Multiple gestation with significant growth discrepancy > 20%

NOTE: A biophysical or modified biophysical profile is generally authorized once a week unless non-reassuring; it may be repeated twice a week. NOTE: A contraction stress test is considered medically necessary following an abnormal non-stress test or modified biophysical profile.

Clinical Coverage Guideline page 3

Original Effective Date: 6/18/2009 - Revised: 6/25/2010, 8/2/2011, 6/7/2012, 12/6/2012, 6/6/2013, 6/5/2014, 5/7/2015, 7/7/2016, 6/1/2017 ANTEPARTUM FETAL SURVEILLANCE HS-111

Fetal umbilical artery Doppler velocimetry (76820) is considered medically necessary for the following:  Fetal growth restriction (EFW < 10th percentile growth); OR,  Monochorionic/diamniotic twins with significant growth discrepancy > 20%; OR,  Twin-twin transfusion syndrome; OR,  Oligohydramnios (AFI < 7 cm)

NOTE: Fetal umbilical artery doppler velocimetry is generally authorized every two weeks. The procedure may be performed more frequently if there is documentation of absent end diastolic velocity/flow, reserved flow or a flow index > 2 SD above the mean for .

Fetal middle cerebral artery Doppler velocimetry (76821) is considered medically necessary for the following:  Risk of fetal anemia; red cell alloimmunization (Rh and non-Rh, parvovirus, fetal infection, feto-maternal hemorrhage; OR,  Twin-twin transfusion syndrome

CODING

Covered CPT®* Codes 59020 Fetal Contraction Stress Test 76818 Fetal biophysical profile; with non-stress testing 76819 Fetal biophysical profile; without non-stress testing 76820 Doppler velocimetry, fetal; umbilical artery 76821 Doppler velocimetry, fetal; middle cerebral artery

HCPCS Codes – No applicable codes.

ICD-10-PCS (Inpatient Only) Refer to the following ICD-10-PCS tables for specific code assignment based on physician documentation. NOTE: Per ICD-10-PCS Coding Guidelines, “ICD-10-PCS codes are composed of seven characters. Each character is an axis of classification that specifies information about the procedure performed. Within a defined code range, a character specifies the same type of information in that axis of classification. One of 34 possible values can be assigned to each axis of classification in the seven-character code”.

Covered ICD-10-CM Diagnosis Codes O10.011 - O10.013- Pre-existing essential hypertension complicating pregnancy O10.02 Pre-existing essential hypertension complicating O11.111 - O10.113 Pre-existing hypertensive heart disease complicating pregnancy O10.12 Pre-existing hypertensive heart disease complicating childbirth O10.211 - O10.213 Pre-existing hypertensive chronic kidney disease complicating pregnancy O10.22 Pre-existing hypertensive chronic kidney disease complicating childbirth O10.311 - O10.313 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy O10.32 Pre-existing hypertensive heart and chronic kidney disease complicating childbirth O10.411 - O10.413 Pre-existing secondary hypertension complicating pregnancy O10.42 Pre-existing secondary hypertension complicating childbirth O10.911 - O10.913 Unspecified pre-existing hypertension complicating pregnancy O19.92 Unspecified pre-existing hypertension complicating childbirth O11.1 - O11.3 Pre-existing hypertension with pre-eclampsia O11.4 Pre-existing hypertension with pre-eclampsia, complicating childbirth O12.00 - O12.03 Gestational (pregnancy-induced) edema and proteinuria without hypertension O12.04 Gestational edema, complicating childbirth O12.10-O12.13 Gestational proteinuria O12.14 Gestational proteinuria, complicating childbirth O12.20-O12.23 Gestational edema with proteinuria O12.24 Gestational edema with proteinuria, complicating childbirth O13.1 - O13.3 Gestational [pregnancy-induced] hypertension without significant proteinuria O13.4 Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating childbirth Clinical Coverage Guideline page 4

Original Effective Date: 6/18/2009 - Revised: 6/25/2010, 8/2/2011, 6/7/2012, 12/6/2012, 6/6/2013, 6/5/2014, 5/7/2015, 7/7/2016, 6/1/2017 ANTEPARTUM FETAL SURVEILLANCE HS-111

O14.00 - O14.03 Mild to moderate pre-eclampsia O14.04 Mild to moderate pre-eclampsia, complicating childbirth O4.10- O14.13 Severe pre-eclampsia O14.14 Severe pre-eclampsia complicating childbirth O14.20-O14.23 HELLP syndrome O14.24 HELLP syndrome, complicating childbirth O14.90 –O14.93 Unspecified pre-eclampsia, unspecified trimester,second,Third trimester O14.94 Unspecified pre-eclampsia, complicating childbirth O15.00 - O15.03 Eclampsia complicating pregnancy O15.1 Eclampsia complicating labor O16.1 - O16.9 Unspecified maternal hypertension O24.410 - O24.415 Gestational diabetes mellitus in pregnancy O24.420 - O42.425 Gestational diabetes mellitus in childbirth O24.911 - O24.913 Unspecified diabetes mellitus in pregnancy First through Third Trimester O26.831 - O26.833 Pregnancy related renal disease O30.001 - O30.003 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sac O30.011-O30.013 Twin pregnancy, monochorionic/monoamniotic O30.021-O30.023 Conjoined twin pregnancy O30.031-O30.033 Twin pregnancy, monochorionic/diamniotic O30.41- O30.043 Twin pregnancy, dichorionic/diamniotic O30.091-O30.93 Twin pregnancy, unable to determine number of placenta and number of amniotic sacs O30.101 - O30.103 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs O30.111-O30.113 Triplet pregnancy with two or more monochorionic fetuses O30.121-O30.123 Triplet pregnancy with two or more monoamniotic fetuses O30.191-O30.199 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs O30.201- O30.203 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs O30.211- O30.213 Quadruplet pregnancy with two or more monochorionic fetuses O30.221- O30.223 Quadruplet pregnancy with two or more monoamniotic fetuses O30.291- O30.293 Quadruplet pregnancy, unable to determine number of placenta & number of amniotic sacs O30.801 - O30.803 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs O30.811 -O30.813 Other specified multiple gestation with two or more monochorionic fetuses O30.821- O30.823 Other specified multiple gestation with two or more monoamniotic fetuses O30.891- O30.893 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs O30.90 - O30.93 Multiple gestation, unspecified O31.00X0-O31.03X9 Papyraceous fetus, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O31.10X0-O31.13X9 Continuing pregnancy after spontaneous abortion of one fetus or more, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O31.20X0- O31.23X9 Continuing pregnancy after intrauterine death of one fetus or more, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O31.30X0-O31.33X9 Continuing pregnancy after elective fetal reduction of one fetus or more, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O31.8X10-O31.8X99 Other complications specific to multiple gestation, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.0110-O36.0199 Maternal care for anti-D [Rh] antibodies, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus

Clinical Coverage Guideline page 5

Original Effective Date: 6/18/2009 - Revised: 6/25/2010, 8/2/2011, 6/7/2012, 12/6/2012, 6/6/2013, 6/5/2014, 5/7/2015, 7/7/2016, 6/1/2017 ANTEPARTUM FETAL SURVEILLANCE HS-111

O36.0910-O36.0999 Maternal care for other rhesus isoimmunization, , Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.1110-O36.1199 Maternal care for Anti-A sensitization, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.1910-O36.1999 Maternal care for other isoimmunization, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.20X0-O36.23X9 Maternal care for hydrops fetalis, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.4XX0-O36.4XX9 Maternal care for intrauterine death, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.5110-O36.5199 Maternal care for known or suspected , Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.5910- O36.5999 Maternal care for other known or suspected poor fetal growth, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.60X0- O36.63X9 Maternal care for excessive fetal growth, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.70X0- O36.73X9 Maternal care for viable fetus in abdominal pregnancy, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.80X0- O36.83X9 Pregnancy with inconclusive fetal viability, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.8120- O36.8199 Decreased fetal movements, Second and Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.8210- O36.8299 Fetal anemia and thrombocytopenia, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.8910- O36.8999 Maternal care for other specified fetal problems, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O36.90X0- O36.93X9 Maternal care for fetal problem, unspecified, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O40.1XX0- O40.9XX9 , Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O41.00X0 O41.03X9 Oligohydramnios, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O41.1010-O41.1099 Infection of amniotic sac and membranes, unspecified, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O41.1210-O41.1299 Chorioamnionitis, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O41.1410- O41.1499 Placentitis, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O41.8X10-O41.8X99 Other specified disorders of amniotic fluid and membranes, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O41.90X0-O41.93X9 Disorder of amniotic fluid and membranes, Not applicable/Unspecified Trimester, First Through Third Trimester, Not applicable/Unspecified Fetus, 1-5 Fetus, other fetus O48.0 Post Term Pregancy O48.1 Prolonged pregnancy O99.011+0-O99.013+ Anemia complicating pregnancy, first through Third Trimester +(Code also specific disease classified under D65 – D89) O99.281 –O99.283 Endocrine, nutritional and metabolic diseases complicating pregnancy, First through Third trimester O99.284 Endocrine, nutritional and metabolic diseases complicating childbirth

Clinical Coverage Guideline page 6

Original Effective Date: 6/18/2009 - Revised: 6/25/2010, 8/2/2011, 6/7/2012, 12/6/2012, 6/6/2013, 6/5/2014, 5/7/2015, 7/7/2016, 6/1/2017 ANTEPARTUM FETAL SURVEILLANCE HS-111

O99.411 –O99.413 Diseases of the circulatory system complicating pregnancy, first through Third trimester O99.42 Diseases of the circulatory system complicating childbirth O99.810 Abnormal glucose complicating pregnancy O99.814 Abnormal glucose complicating childbirth

*Current Procedural Terminology (CPT) 2016 American Medical Association: Chicago, IL.®©

REFERENCES

1. American College of Obstetricians and Gynecologists. (2006). ACOG practice bulletin no. 75: management of alloimmunization. and Gynecology, 108(2), 457-464. 2. American College of Obstetricians and Gynecologists. (2014). ACOG practice bulletin no. 145: antepartum fetal surveillance. Obstet Gynecol 2014;124:182–92. 3. American College of Obstetricians and Gynecologists (2009). ACOG technical bulletin no. 106 Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Obstet Gynecol 2009;114:192–202). 4. American College of Obstetricians and Gynecologists & American Academy of Pediatrics. (2012). Guidelines for perinatal care. 7th Ed. Washington, DC: ACOG. 5. American College of Radiology Expert Panel on Women's Imaging. (2012). Growth disturbances: risk of intrauterine growth restriction. Reston, VA.

MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS

Date Action

6/1/2017  Approved by MPC. Coding updates only. 7/7/2016, 5/7/2015, 6/5/2014, 6/6/2013  Approved by MPC. No changes. 12/6/2012  Approved by MPC. Updated coding related to amniotic fluid index and fetal biophysical profile. 6/7/2012  Approved by MPC. No changes. 12/1/2011  New template design approved by MPC. 8/2/2011  Approved by MPC. New.

Clinical Coverage Guideline page 7

Original Effective Date: 6/18/2009 - Revised: 6/25/2010, 8/2/2011, 6/7/2012, 12/6/2012, 6/6/2013, 6/5/2014, 5/7/2015, 7/7/2016, 6/1/2017