June 18, 2021
Dear Kentucky Provider,
WellCare is implementing the following policy for Ultrasound in Pregnancy with an effective date of July 25, 2021.
Summary of Policy:
This policy outlines the medical necessity criteria for ultrasound use in pregnancy. It is the policy of health plans affiliated with WellCare Health Plans Inc. that the following ultrasounds during pregnancy are considered medically necessary when the following conditions are met:
- Standard first trimester ultrasound (76801)
- Standard second or third trimester ultrasound (76805)
- Detailed anatomic ultrasound (76811)
- Transvaginal ultrasound (76817)
- Not medically necessary conditions
- One standard first trimester ultrasound (76801) is allowed per pregnancy.
Subsequent standard first trimester ultrasounds are considered not medically necessary as a limited or follow-up ultrasound assessment (76815 or 76816) should be sufficient to provide a re-examination of suspected concerns.
- One standard second or third trimester ultrasound (76805) is allowed per pregnancy.
Subsequent standard second or third trimester ultrasounds are considered not medically necessary as a limited or follow-up ultrasound assessment (76815 or 76816) should be sufficient to provide a re-examination of suspected concerns.
- One detailed anatomic ultrasound (76811) is allowed per pregnancy when performed to evaluate for suspected anomaly based on history, laboratory abnormalities, or clinical evaluation; or when there are suspicious results from a limited or standard ultrasound. Further indications include the possibility of fetal growth restriction and multifetal gestation. This ultrasound must be billed with an appropriate high risk diagnosis code (see CPP 157).
A second detailed anatomic ultrasound is considered medically necessary if a new maternal fetal medicine specialist group is taking over care, a second opinion is required, or the patient has been transferred to a tertiary care center in anticipation of delivery of an anomalous fetus requiring specialized neonatal care. Further anatomic ultrasounds are considered not medically necessary as there is inadequate evidence of the clinical utility of multiple detailed fetal anatomic examinations.
- Transvaginal ultrasounds (TVU) (76817) are considered medically necessary when conducted in the first trimester for the same indications as a standard first trimester ultrasound, and later in pregnancy to assess cervical length, location of the placenta in women with placenta previa, or after an inconclusive transabdominal ultrasound. Cervical length screening is conducted for women with a history of preterm labor or to monitor a shortened cervix based on Table 1 below. Up to 12 transvaginal ultrasounds are allowed per pregnancy.
- 3D and 4D ultrasounds (76376, 76377) are considered investigational and are therefore not medically necessary. Studies lack sufficient evidence that they alter management over two-dimensional ultrasound in a fashion that improves outcomes.
The following additional procedures are considered not medically necessary:
- Ultrasounds performed solely to determine the sex of the fetus or to provide parents with photographs of the fetus;
- Scans for growth evaluation performed less than 2 weeks apart;
- Ultrasound to confirm pregnancy in the absence of other indications;
- A follow-up ultrasound in the fist trimester in the absence of pain or bleeding.
What does this mean for providers?
When a provider bills outside of the established edit criteria as determined by American College of Obstetricians and Gynecologists (ACOG) and the Society of Maternal Fetal Medicine as stated in the policy, their claim may deny.
WellCare is committed to assisting the provider during this time of adjustment. Additional information regarding the policy will be made available during the implementation process.
If Kentucky providers do not agree with WellCare’s decision, they may appeal the denial. WellCare may require medical records that substantiate provider billing.
Providers can review the complete policy at https://www.wellcare.com/en/Kentucky/Providers, select Claims, then Payment Policy.
We are here to help. Please contact your Network Representative for general inquiries regarding this program.
WellCare Health Plans