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Number: 0106

Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

I. Aetna considers fetal echocardiograms, Doppler and color flow mapping medically necessary for any of the following conditions:

A. A mother with insulin dependent diabetes mellitus or

systemic lupus erythematosus; or B. As a screening study in families with a first‐degree

relative with a history of congenital heart disease; or C. Fetal nuchal translucency measurement of 3.5 mm or

greater in the first trimester; or D. Following an abnormal or incomplete cardiac evaluation

on an anatomic scan, 4‐chamber study (Note: When the 4‐chambered view is adequate and there are no other indications of a cardiac abnormality, a fetal echocardiogram is not considered medically necessary); or

Last Review 01/26/2017 Effective: 05/08/1996 Next Review: 01/25/2018

Review History

Definitions

Clinical Policy Bulletin Notes

E. For ductus arteriosus dependent lesions and/or with

other known complex congenital heart disease; or F. For pregnancies conceived by in vitro fertilization (IVF) or

intra‐cytoplasmic sperm injection (ICSI); or

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G. In cases of single umbilical artery; or H. In cases of suspected or known fetal chromosomal

abnormalities; or I. In suspected or documented fetal arrhythmia: to define

the rhythm and its significance, to identify structural heart disease and cardiac function; or

J. In members with autoimmune antibodies associated with congenital cardiac anomalies [anti‐Ro (SSA)/anti‐La (SSB)]; or

K. In members with familial inherited disorders associated with congenital cardiac abnormalities (e.g., Marfan syndrome); or

L. In cases with monochorionic twins; or M. In cases of multiple gestation and suspicion of twin‐twin

transfusion syndrome; or N. In members with seizure disorders, even if they are not

presently taking anti‐seizure medication; or O. In cases with non‐immune fetal hydrops or unexplained

severe polyhydramnios; or P. When members' fetuses have been exposed to drugs

known to increase the risk of congenital cardiac abnormalities including but not limited to:

Anti‐seizure medications; or Excessive alcohol intake; or Lithium; or Paroxetine (Paxil); or Retinoids; or

Q. When other structural abnormalities are found on ultrasound; or

II. Aetna considers repeat studies of fetal echocardiograms

medically necessary when the initial screening study indicates any of the following:

A ductus arteriosus dependent lesion; or Structural heart disease with a suggestion of

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hemodynamic compromise; or Tachycardia other than sinus tachycardia or heart block.

III. Aetna considers fetal echocardiograms experimental and investigational for all other indications including the following (not an all‐inclusive list) (e.g., suspected cystic fibrosis, as a screening test in advanced maternal age) because their effectiveness for these indications has not been established.

As a screening test in advanced maternal age; or Pregnant women receiving selective serotonin reuptake inhibitors (except paroxetine); or Suspected cystic fibrosis.

Background Definition of fetal cardiac structures is currently possible at 10 to 12 weeks of gestation with the use of vaginal probes with high‐resolution transducers. With current technologies, accurate segmental analysis of cardiac structures and blood flow across valves, shunts, and the ductus arteriosus is possible with a conventional transabdominal approach by 16 to 18 weeks of gestation.

Patients are referred for fetal echocardiography because of an abnormality of structure or rhythm noted on ultrasound examination or because the patient is in a high‐risk group for fetal heart disease. Treatment of the patient is facilitated by the early recognition of the exact nature of the cardiac problem in the fetus. The correct diagnosis may be difficult because of fetal physiology, the effect on flow across defects and valves, inability to see the fetus for orientation reference, and inability to examine the fetus for clinical findings. For these reasons, fetal echocardiography should be performed only by trained fetal echocardiographers.

A single umbilical artery (SUA) is present in 0.2 % to 0.6 % of live births, occurring more frequently in twins and in small for gestational age and premature infants. In infants with SUA,

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there is an increased rate of chromosomal and other congenital anomalies. Studies have shown that 20 % to 30 % of neonates with SUA had major structural anomalies, frequently involving multiple organs (Palazzi and Brandt, 2009; Thummala et al, 1998). The most commonly affected organ is the heart. Single umbilical artery is an isolated finding in the remaining 70 % to 80 % of infants.

Conception by in vitro fertilization (IVF) or intra‐cytoplasmic sperm injection (ICSI) has been associated with an increased incidence of fetal heart defects. A meta‐analyses on the prevalence of birth defects in infants conceived following IVF and/or ICSI compared with spontaneously conceived infants reported a 30 % to 40 % increased risk of birth defects associated with IVF and/or ICSI (Hansen et al, 2005). Researchers have reported that infants conceived with the use of IVF and/or ICSI have a 2‐to‐4‐fold increase of heart malformations compared with naturally conceived infants.

Kurinczuk and Bower (1997) examined the prevalence of birth defects on 420 liveborn infants who were conceived after ICSI in Belgium compared with 100,454 liveborn infants in Western Australia delivered during the same period. Infants born after ICSI were twice as likely as Western Australian infants to have a major birth defect [odds ratio (OR) 2.03, 95 % confidence interval (CI): 1.40 to 2.93); p = 0.0002] and nearly 50 % more likely to have a minor defect (OR 1.49 (0.48 to 4.66); p = 0.49). Secondary data‐led analyses found an excess of major cardiovascular defects (OR 3.99).

Koivurova et al (2002) evaluated the neonatal outcome and the prevalence of congenital malformations in children born after IVF in northern Finland in a population‐based study with matched controls. Children born after IVF (n = 304) in 1990 to1995 were compared with controls (n = 569), representing the general population in proportion of multiple births, randomly chosen from the Finnish Medical Birth Register (FMBR) and matched for sex, year of birth, area of residence, parity, maternal age and social class. Plurality matched controls

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were randomly chosen from the FMBR and analyzed separately. Additionally, IVF singletons were compared with singleton controls. The prevalence of heart malformations was four‐fold in the IVF population than in the controls representing the general population (OR 4.0, 95 % CI: 1.4 to 11.7).

Reefhuis et al (2009) analyzed data from the National Birth Defects Prevention Study, a population‐based, multi‐center, case‐control study of birth defects. Included were mothers of fetuses or live‐born infants with a major birth defect (case infants) and mothers who had live‐born infants who did not have a major birth defect (control infants), delivered during the period October 1997 to December 2003. Mothers who reported IVF or ICSI use were compared with those who had unassisted conceptions. Among singleton births, IVF or ICSI use was associated with septal heart defects (adjusted odds ratio [aOR] = 2.1, 95 % CI: 1.1 to 4.0).

As fetal heart disease is typically associated with structural abnormalities and consequent aberrant blood flow through the heart, it is necessary to perform Doppler studies and color flow mapping when such abnormalities are detected with 2D fetal echocardiography.

The American College of Obstetricians and Gynecologists' Committee Opinion on the treatment with selective serotonin reuptake inhibitors during pregnancy (ACOG, 2006) noted that paroxetine use among pregnant women and women planning pregnancy should be avoided, if possible. Fetal echocardiography should be considered for women who were exposed to paroxetine in early pregnancy.

In a practice bulletin on screening for fetal chromosomal anomalies, ACOG (2007) has stated that patients who have a fetal nuchal translucency measurement of 3.5 mm or greater in the first trimester, despite a negative result on an aneuploidy screen, normal fetal chromosomes, or both, should be offered a targeted ultrasound examination, fetal echocardiogram, or both, because such fetuses are at a significant risk for

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non‐chromosomal anomalies, including congenital heart defects, abdominal wall defects, diaphragmatic hernias, and genetic syndromes.

Twin‐twin transfusion syndrome (TTTS) is a severe complication of monochorionic (1 placenta) twin pregnancies, characterized by the development of unbalanced chronic blood transfer from one twin, defined as donor twin, to the other, defined as recipient, through placental anastomoses. If left untreated, TTTS is associated with very high peri‐natal mortality and morbidity rates; and fetuses who survive are at risk of severe cardiac, neurological, and developmental disorders.

The American Society of Echocardiography's guidelines and standards for performance of the fetal echocardiogram (Rychik et al, 2004) stated that multiple gestation and suspicion of TTTS is an indication of fetal echocardiography.

Bahtiyar et al (2007) noted that congenital heart defects (CHDs) affect approximately 0.5 % of all neonates. Recent literature points to a possible increase in the CHD prevalence among monochorionic/diamniotic (MC/DA) twin gestations. These researchers hypothesized that MC/DA twin pregnancy is a risk factor for CHD. A systematic review of all published English literature was conducted on MEDLINE (Ovid and PubMed) from January 2000 through April 2007 using the medical subject heading terms "congenital heart defect" and "monozygotic twins". Four observational studies were included in the final analysis. Published historical data were used for the population background risk of CHD. Relative risk (RR) estimates with 95 % confidence intervals (CIs) were calculated by fixed and random effect models. These investigators included a total of 40 fetuses with CHDs among 830 fetuses from MC/DA twin gestations. Compared with the population, CHDs were significantly more prevalent in MC/DA twins regardless of the presence of TTTS (RR, 9.18; 95 % CI: 5.51 to 15.29; p < 0.001). Monochorionic/diamniotic twin gestations affected by TTTS were more likely to be complicated by CHDs than those that did not have TTTS (RR, 2.78; 95 % CI: 1.03 to 7.52; p = 0.04).

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Ventricular septal defects were the most frequent heart defects. Pulmonary stenosis and atrial septal defects were significantly more prevalent in pregnancies complicated with TTTS. The authors concluded that MC/DA twin gestation appears to be a risk factor for CHDs. Conditions that lead to abnormal placentation may also contribute to abnormal heart development, especially in MC/DA twin pregnancies complicated with TTTS. Fetal echocardiography may be considered for all MC/DA twin gestations because ventricular septal defects and pulmonary stenosis are the most common defects.

The Royal College of Obstetricians and Gynaecologists' clinical practice guidelines on "Management of monochorionic twin pregnancy" (RCOG, 2008) stated that a fetal echocardiographic assessment should be considered in the assessment of severe TTTS.

Pregnant Women Receiving Selective Serotonin Reuptake Inhibitors:

Reefhuis and colleagues (2015) followed up on previously reported associations between peri‐conceptional use of selective serotonin reuptake inhibitors (SSRIs) and specific birth defects using an expanded dataset from the National Birth Defects Prevention Study. These researchers performed a Bayesian analysis combining results from independent published analyses with data from a multi‐center population based case‐control study of birth defects. A total of 17,952 mothers of infants with birth defects and 9,857 mothers of infants without birth defects, identified through birth certificates or birth hospitals, with estimated dates of delivery between 1997 and 2009 were included in this analysis; exposures were citalopram, escitalopram, fluoxetine, paroxetine, or sertraline use in the month before through the 3rd month of pregnancy. Posterior OR estimates were adjusted to account for maternal race/ethnicity, education, smoking, and pre‐pregnancy obesity. Main outcome measure was 14 birth defects categories that had associations with SSRIs reported in

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the literature. Sertraline was the most commonly reported SSRI, but none of the 5 previously reported birth defects associations with sertraline was confirmed. For 9 previously reported associations between maternal SSRI use and birth defect in infants, findings were consistent with no association. High posterior ORs excluding the null value were observed for 5 birth defects with paroxetine (anencephaly 3.2, 95 % CI: 1.6 to 6.2; atrial septal defects 1.8, 95 % CI: 1.1 to 3.0; right ventricular outflow tract obstruction defects 2.4, 95 % CI: 1.4 to 3.9; gastroschisis 2.5, 95 % CI: 1.2 to 4.8; and omphalocele 3.5, 95 % CI: 1.3 to 8.0) and for 2 defects with fluoxetine (right ventricular outflow tract obstruction defects 2.0, 95 % CI: 1.4 to 3.1 and craniosynostosis 1.9, 95 % CI: 1.1 to 3.0). The authors concluded that these data provided reassuring evidence for some SSRIs; but suggested that some birth defects occurred 2 to 3.5 times more frequently among the infants of women treated with paroxetine or fluoxetine early in pregnancy.

A 2015 study by the Centers for Disease Control and Prevention (CDC) used new data to examine previous reported links between use of specific SSRIs medications just before or during early pregnancy and the occurrence of certain birth defects. Researchers looked at links with 5 different SSRI medications: citalopram, escitalopram, fluoxetine, paroxetine, and sertraline. Although the new data confirmed the risks seen with paroxetine, it did not appear to suggest that the risk is across the board with all SSRIs. Therefore, fetal echocardiography is still recommended for women exposed to paroxetine, but there doesn’t seem to be enough evidence to recommend coverage of fetal echocardiograms for all pregnant members receiving any SSRI. The study concluded that despite the increased risks for certain birth defects from some SSRIs found in this study, the actual risk for a birth defect among babies born to women taking one of these medications is still very low. Because these specific types of birth defects are rare, even doubling the risk still results in a low absolute risk. For example, the risks for heart defects with obstruction of the right ventricular outflow tract could increase from 10 per 10,000 births to about 24 per 10,000 births among babies of women who are treated with

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paroxetine early in pregnancy. http://www.cdc.gov/pregnancy /meds/treatingfortwo/features/ssrisandbirthdefects.html (http://www.cdc.gov/pregnancy/meds/treatingfortwo /features/ssrisandbirthdefects.html).

Appendix

Documentation Requirements for Fetal Echocardiography:

According to guidelines from the American Institute for Ultrasound in Medicine (AIUM), fetal echocardiography should include the following cardiac images:

Aortic arch; Ductal arch; Four‐chamber view; Inferior vena cava; Left ventricular outflow tract; Right ventricular outflow tract; Short‐axis views (“low” for ventricles and “high” for outflow tracts); Superior vena cava; and Three‐vessel and trachea view.

According to the 2010 AIUM's practice guideline on "Performance of Fetal Echocardiography", indications for fetal echocardiography are often based on a variety of parental and fetal risk factors for congenital heart disease. However, most cases are not associated with known risk factors. Common indications for a detailed scan of the fetal heart include but are not limited to:

Maternal Indications Associated with Congenital Heart Disease:

Autoimmune antibodies [anti‐Ro (SSA)/anti‐La (SSB)] Familial inherited disorders (e.g., Marfan syndrome) First‐degree relative with congenital heart disease In‐vitro fertilization Metabolic disease (e.g., diabetes mellitus and

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phenylketonuria) Teratogen exposure (e.g., lithium and retinoids)

Fetal Indications:

Abnormal cardiac screening examination Abnormal heart rate or rhythm Fetal chromosomal anomaly Extra‐cardiac anomaly Hydrops Increased nuchal translucency Monochorionic twins Unexplained severe polyhydramnios

This AIUM practice guideline was published in conjunction with the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal‐Fetal Medicine (SMFM). Furthermore, this practice guideline was endorsed by the American College of Radiology (ACR).

Source: AIUM, February 2010. Available at: https://www.smfm.org/attachedfiles/fetalEchoaiumsmfm.pdf (https://www.smfm.org/attachedfiles /fetalEchoaiumsmfm.pdf)

CPT Codes / HCPCS Codes / ICD‐10 Codes

Informa'tion in the [brackets] below has been added for

clarifica'tion purposes. Codes requiring a 7th character are

represented by "+":

CPT codes covered if selection criteria are met:

76825 Echocardiography, fetal, cardiovascular system, real

time with image documentation (2D), with or

without M‐mode recording;

76826 follow‐up or repeat study

76827 Doppler echocardiography, fetal, cardiovascular

system, pulsed wave and/or continuous wave with

spectral display; complete

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76828 follow‐up or repeat study

+93325 Doppler echocardiography color flow velocity

mapping (List separately in addition to codes for

echocardiography)

Other HCPCS codes related to the CPB:

Q9950 Injection, sulfur hexafluoride lipid microspheres, per

ml

Maternal ICD‐10 codes covered if selection criteria are met:

B97.10,

B97.89

Unspecified viral infection

E10.10 ‐

E13.9

Diabetes mellitus [do not report for gestational

diabetes]

F10.20 ‐

F10.29

Alcohol dependence

G40.001 ‐

G40.919

Epilepsy and recurrent seizures

I34.0 ‐ I37.9 Mitral valve disorders, aortic valve disorders,

tricuspid valve disorders and pulmonary valve

disorders, specified as nonrheumatic,

I42.3 Endomyocardial (eosinophilic) disease

I42.4 Endocardial fibroelastosis

I42.6 Alcoholic cardiomyopathy

I51.7 Cardiomegaly

I78.0 Hereditary hemorrhagic telangectasia

L93.0 ‐

L93.2

Lupus erythematosus

M05.40 ‐

M06.9

Rheumatoid arthritis

M32.0 ‐

M32.9

Systemic lupus erythematosus

M34.0 ‐

M34.9

Systemic sclerosis [scleroderma]

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M35.00 ‐

M35.09

Sicca syndrome [Sjögren]

M35.9,

M36.8

Unspecified diffuse connective tissue disease

O24.011 ‐ Diabetes mellitus in pregnancy [pre‐existing, O24.019, excludes gestational diabetes]

O24.111 ‐

O24.119

O24.311 ‐

O24.319,

O24.811 ‐

O24.819

O24.911 ‐

O24.919

O30.001 ‐

O30.93

Multiple gestation

O98.411 ‐ Viral hepatitis and other viral diseases complicating O98.419, pregnancy

O98.511 ‐

O98.519

O98.611 ‐ Other specified infectious and parasitic diseases O98.619, complicating pregnancy

O98.711 ‐

O98.719

O98.811 ‐

O98.819,

O99.830

O98.911 ‐ Unspecified maternal infectious and parasitic O98.93 diseases complicating pregnancy, childbirth and the

puerperium

O99.350 ‐ Diseases of the nervous system complicating O99.353 pregnancy [epilepsy]

O99.411 ‐ Diseases of the circulatory system complicating O99.419 pregnancy

Q20.0 ‐

Q28.9

Congenital malformations of the circulatory system

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Q79.6 Ehlers‐Danlos syndrome

Q87.40 ‐

Q87.43

Marfan's syndrome

Q89.3 Situs inversus

Q89.7 Multiple congenital malformations, not elsewhere

classified

Q90.0 ‐

Q90.9

Down syndrome

Q91.0 ‐

Q91.3

Trisomy 18 [Edward's syndrome]

R56.1 Post traumatic seizures

R56.9 Unspecified convulsions [seizure disorder NOS]

R93.1, R93.8 Abnormal findings on diagnostic imaging of heart

and coronary circulation and other body structures

T42.1x5+,

T42.5x5+

T42.6x5+,

T42.75x+

Adverse effects of other and unspecified

anticonvulsants

Z82.79 Family history of other congenital malformations,

deformations and chromosomal abnormalities

Z98.89 Other specified postprocedural states

Fetal ICD‐10 codes covered if selection criteria are met:

O09.811 ‐

O09.819

Supervision of pregnancy resulting from assisted

reproductive rechnology

O33.6xx0 ‐

O33.6xx9

Maternal care for disproportion due to hydrocephalic

fetus

O35.0xx0 ‐

O35.0xx9

Maternal care for (suspected) central nervous system

malformation in fetus

O35.1xx0 ‐

O35.1xx9

Maternal care for (suspected) chromosomal

abnormality in fetus

O35.2xx0 ‐

O35.2xx9

Maternal care for (suspected) hereditary disease in

fetus

O35.3xx0 ‐

O35.3xx9

Maternal care for (suspected) damage to fetus from

viral disease in mother

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O35.4xx0 ‐

O35.4xx9

Maternal care for (suspected) damage to fetus from

alcohol

O35.5xx0 ‐

O35.5xx9

Maternal care for (suspected) damage to fetus from

drugs

O35.8xx0 ‐

O35.8xx9

Maternal care for (suspected) fetal abnormality and

damage

O35.9xx0 ‐

O35.9xx9

Maternal care for (suspected) fetal abnormality and

damage, unspecified

O36.0110 ‐

O36.0999

Maternal care for rhesus isoimmunization

O36.1110 ‐

O36.1999

Maternal care for other isoimmunization

O40.1XX0 ‐

O40.3XX9

Polyhydramnios

O43.011 ‐

O43.029

Placenta transfusion syndromes

O76 Abnormality in fetal heart rate and rhythm

complicating labor and delivery

P02.3 Newborn (suspected to be) affected by placental

transfusion syndromes

P03.810 Newborn affected by abnormality in fetal

(intrauterine) heart rate or rhythm before the onset

of labor

P03.819 Newborn affected by abnormality in fetal

(intrauterine) heart rate or rhythm, unspecified as to

time of onset

P04.1,

Q86.1

Newborn (suspected to be) affected by other

maternal medication or fetal hydantoin syndrome

P04.3,

Q86.0

Newborn (suspected to be) affected by maternal use

of alcohol or fetal alcohol syndrome

P70.0 ‐

P70.1

Syndrome of infant of mother with gestational

diabetes or infant of a diabetic mother

P83.2 Hydrops fetalis not due to hemolytic disease

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Q27.0 Congenital absence and hypoplasia of umbilical

artery

ICD‐10 codes covered if selection criteria are met:

O09.811 ‐

O09.819

Supervision of pregnancy resulting from assisted

reproductive rechnology

O24.011 ‐ Diabetes mellitus in pregnancy [pre‐existing, O24.019, excludes gestational diabetes]

O24.111 ‐

O24.119

O24.311 ‐

O24.319,

O24.811 ‐

O24.819

O24.911 ‐

O24.919

O33.6xx0 ‐

O33.6xx9

Maternal care for disproportion due to hydrocephalic

fetus

O35.0xx0 ‐

O35.0xx9

Maternal care for (suspected) central nervous system

malformation in fetus

O35.1xx0 ‐

O35.1xx9

Maternal care for (suspected) chromosomal

abnormality in fetus

O35.2xx0 ‐

O35.2xx9

Maternal care for (suspected) hereditary disease in

fetus

O35.3xx0 ‐

O35.3xx9

Maternal care for (suspected) damage to fetus from

viral disease in mother

O35.4xx0 ‐

O35.4xx9

Maternal care for (suspected) damage to fetus from

alcohol

O35.5xx0 ‐

O35.5xx9

Maternal care for (suspected) damage to fetus from

drugs

O35.8xx0 ‐

O35.8xx9

Maternal care for (suspected) fetal abnormality and

damage

O35.9xx0 ‐

O35.9xx9

Maternal care for (suspected) fetal abnormality and

damage, unspecified

O36.0110 ‐

O36.0999

Maternal care for rhesus isoimmunization

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O36.1110 ‐

O36.1999

Maternal care for other isoimmunization

O40.1xx0 ‐

O40.1xx9

Polyhydramnios

O43.011 ‐

O43.029

Placenta transfusion syndromes

O76 Abnormality in fetal heart rate and rhythm

complicating labor and delivery

O98.411 ‐ Viral hepatitis and other viral diseases complicating O98.419, pregnancy

O98.511 ‐

O98.519

O98.611 ‐ Other specified infectious and parasitic diseases O98.619, complicating pregnancy

O98.711 ‐

O98.719

O98.811 ‐

O98.819,

O99.830

O98.911 ‐ Unspecified maternal infectious and parasitic O98.919 diseases complicating pregnancy

O99.411 ‐ Diseases of the circulatory systerm complicating O99.419 pregnancy

Q27.0 Congenital absence and hypoplasia of umbilical

artery

ICD‐10 codes not covered for indications listed in the CPB (not

all‐inclusive):

O09.511 ‐

O09.519

Supervision of elderly primigravida

O09.521 ‐

O09.529

Supervision of elderly multigravida

O99.810 ‐ Abnormal glucose complicating pregnancy, childbirth O99.815 and the puerperium

Z13.228 Encounter for screening for other metabolic

disorders

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The above policy is based on the following references: 1. Cheitlin MD, Alpert JS, Armstrong WF, et al. ACC/AHA

Guidelines for the clinical application of echocardiography: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Clinical Application of Echocardiography). Developed in collaboration with the American Society of Echocardiography. J Am Coll Cardiol. 1997;29(4):862‐879.

2. Winsberg F. Echocardiography of the fetal and newborn heart. Invest Radiol. 1972;3:152‐158.

3. Copel JA, Pilu G, Kiemman CS. Congenital heart disease and extracardiac anomalies: Associations and indications for fetal echocardiography. Am J Obstet Gynecol. 1986;541:1121‐1132.

4. Kiemman CS, Donnerstein RY, DeVore OR. Fetal echocardiography for evaluation of in utero congestive cardiac failure: A technique for study of non‐immune hydrops. N Engl J Med. 1982;306:568‐575.

5. DeVore OR, Donnerstein RL, Klemman CS, et al. Fetal echocardiography. II. The diagnosis and significance of a pericardial effusion in the fetus using real‐time‐directed M‐mode ultrasound. Am J Obstet Gynecol. 1982;144:693‐700.

6. Nora JJ, Nora AH. The evolution of specific genetic and environmental counseling in congenital heart diseases. Circulation. 1978;57:205‐213.

7. Cyr DR, Guntheroth WO, Mack LA, et al. A systematic approach to fetal echocardiography using real‐time/A two‐dimensional sonography. J Ultrasound Med. 1986;5(6):343‐350.

8. Silverman NH, Golbus MS. Echocardiographic techniques for assessing normal and abnormal fetal cardiac anatomy. J Am Coll Cardiol. 1985;5(Suppl 1):20S‐29S.

9. Sahn DJ. Resolution and display requirements for ultrasound/Doppler evaluation of the heart in children, infants and unborn human fetus. J Am Coll Cardiol.

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transverse diameter of the fetal heart: A potential source of error. J Ultrasound Med. 1985;4:335‐341.

11. DeVore OR, Siassi B, Platt LD. Fetal echocardiography. IV. M‐mode assessment of ventricular size and contractility during the second and third trimesters of pregnancy in the normal fetus. Am J Obstet Gynecol. 1984;150:981‐988.

12. DeVore OR, Donnerstein RL, Kiemman CS, et al. Fetal echocardiography. I. Normal anatomy as determined by real‐time‐directed M‐mode ultrasound. Am J Obstet Gynecol. 1982;144:249‐260.

13. St. John Sutton MG, Oewitz MH, Shah B, et al. Quantitative assessment of growth and function of the cardiac chambers in the normal human fetus: A prospective longitudinal echocardiographic study. Circulation. 1984;69(4):645‐654.

14. Azancot A, Caudell TP, Allen HD, et al. Analysis of ventricular shape by echocardiography in normal fetuses, newborns, and infants. Circulation. 1983;68:1201‐1211.

15. Allan LD, Joseph MC, Boyd EG, et al. M‐mode echocardiography in the developing human fetus. Br Heart J. 1982;47(6):573‐583.

16. DeVore OR, Siassi B, Platt LD. Fetal echocardiography. V. M‐mode measurements of the aortic root and aortic valve in second and third trimester normal human fetuses. Am J Obstet Gynecol. 1985;152:543‐550.

17. Shime J, Gresser CD, Rakowski H. Quantitative two‐dimensional echocardiographic assessment of fetal growth. Am J Obstet Gynecol. 1986;154:290‐300.

18. Huhta JC, Strasburger JF, Carpenter RJ, et al. Pulsed Doppler fetal echocardiography. J Clin Ultrasound. 1985;13:247‐254.

19. Maulik D, Nanda NC, Saini VD. Fetal Doppler echocardiography: Methods and characterization of normal and abnormal hemodynamics. Am J Cardiol. 1984;53:572‐578.

20. Schulman H, Fleischer A, Stern W, et al. Umbilical velocity

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wave ratios in human pregnancy. Am J Obstet Gynecol. 1984;148:985‐990.

21. Chen HY, Lu CC, Cheng YT, et al. Antenatal measurement of fetal umbilical venous flow by pulsed Doppler and B‐mode ultrasonography. J Ultrasound Med. 1986;5:319‐321.

22. Reed KL, Sahn DJ, Scagnelli S, et al. Doppler echocardiographic studies of diastolic function in the human fetal heart: Changes during gestation. J Am Coll Cardiol. 1986;8:391‐395.

23. Kiemman CS, Copel JA, Weinstein EM, et al. Treatment of fetal supraventricular tachyarrhythmias. J Clin Ultrasound. 1985;13:265‐273.

24. Allan LD, Anderson RH, Sullivan ID, et al. Evaluation of fetal arrhythmias by echocardiography. Br Heart J. 1983;50(3):240‐245.

25. Keinman CS, Hobbins JC, Jaffe CC, et al. Echocardiographic studies of the human fetus: Prenatal diagnosis of congenital heart disease and cardiac dysrhythmias. Pediatrics. 1980;65:1059‐1067.

26. Silverman NH, Enderlein MA, Stanger P, et al. Recognition of fetal arrhythmias by echocardiography. J Clin Ultrasound. 1985;13:255‐263.

27. McCue CM, Mantakas ME, Tinglestad JB, et al. Congenital heart block in newborns of mothers with connective tissue disease. Circulation. 1977;56:82‐89.

28. Mapp T. Fetal echocardiography and congenital heart disease. Prof Care Mother Child. 2000;10(1):9‐11.

29. Srinivasan S. Fetal echocardiography. Indian J Pediatr. 2000;67(7):515‐521.

30. Tometzki AJ, Suda K, Kohl T, et al. Accuracy of prenatal echocardiographic diagnosis and prognosis of fetuses with conotruncal anomalies. J Am Coll Cardiol. 1999;33(6):1696‐1701.

31. Frommelt MA, Frommelt PC. Advances in echocardiographic diagnostic modalities for the pediatrician. Pediatr Clin North Am. 1999;46(2):427‐439, xi.

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AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number CPB 0106

Fetal Echocardiograms There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania Updated 05/2017