Clinical Policy: Abortions

Reference Number: SC.CP.MP.01
Date of Last Revision: 03/25

[Coding Implications](Coding Implications)
[Revision Log](Revision Log)

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.

Description

This policy describes the medical necessity requirements for coverage of abortions that is in accordance with federal laws and regulations, including 42 CFR 441.203, 441.206, and Hyde Amendment included in the annual L-HHS-Ed appropriations acts and state laws and regulations in the South Carolina Code of Laws, Titles 43 and 44 for Absolute Total Care’s Medicaid members.

Policy/Criteria

III. It is the policy of Absolute Total Care that selective reduction abortions require mandatory secondary medical director review.

IV. It is the policy of Absolute Total Care that abortions including spontaneous, missed, incomplete, septic, hydatidiform mole, etc. (list is not comprehensive), require mandatory secondary medical director review and only require the medical records and clinical notes to verify and confirm the diagnosis. These medical records should be included with all abortion authorization requests and claims.

V. It is the policy of Absolute Total Care that following federal and state laws and regulations, induced, non-therapeutic abortions are not medically necessary. In addition to the abortion procedure itself, per federal statute and South Carolina Code of Laws, any other service(s) rendered as part of and in support of the abortion are deemed not medically necessary.

Note: Providers must follow South Carolina state laws, policies and procedures when performing abortions.

Background

Therapeutic Abortion- For the purpose of this policy and legal statute, is defined as the medically necessary ending of a pregnancy as a result of medical intervention (via pharmaceutical and/or clinical procedure) due to a clinically significant reason, such as the development of a serious maternal complication(s) caused by or made worse by the pregnancy, the increased risk of maternal death if pregnancy continues or during childbirth (not including psychological or emotional conditions), or the pregnancy is the result of rape, incest, or sexual assault.

Spontaneous Abortion- The spontaneous loss of a pregnancy before 20 weeks of gestation due to an underlying medical, biological, genetic, or idiopathic clinical cause. The reason for the pregnancy loss may be the result of one or more factors such as an underlying chronic or acute disease or illness, genetic anomaly, biologic incompatibility, or other clinical reason(s) with an identified etiology. However, more commonly, the cause is idiopathic with no known or definitive etiology. This term is used synonymously with and referred to in layman terms as a miscarriage.

Induced Abortion- The ending of a pregnancy as a result of medical intervention (via pharmaceutical and/or clinical procedure) for any reason(s) other than the pregnancy being the result of rape or incest, risk of maternal death, or other serious maternal medical condition. These other reason(s) include, but are not limited to, not wanting to be pregnant, not financially or emotionally ready to be a parent, because of any kind genetic anomaly, including congenital conditions where there is a high risk of fetal death during pregnancy or shortly after birth, the desire to focus on a career, because of an issue with a partner, including being in an unstable or abusive relationship, etc.

Coding Implications

This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

CPT® Codes That Support Coverage Criteria for Therapeutic Abortion

ICD-10® Codes That Support Coverage Criteria for Therapeutic Abortion

ICD-10® Codes That Support the need for Medical Records for Spontaneous Abortions

ICD-10® Codes That Do Not Require Documentation for Spontaneous Abortions

Reviews, Revisions, and Approvals

4. MCO Medicaid Provider Manual 2024 Absolute Total Care. Healthy Connections. https://www.absolutetotalcare.com/providers/resources/forms-resources.html. Updated September 30, 2024. Accessed February 4, 2025.
5. The American College of Obstetricians and Gynecologists (ACOG), Guide to language and abortion. https://www.acog.org/contact/media-center/abortion-language-guide. Updated October 4, 2024. Accessed February 4, 2025.
6. Salganicoff A, Sobel L, Gomez I, Ramaswamy A. The Hyde Amendment and coverage for abortion services under Medicaid in the post-Roe era. https://www.kff.org/womens-health-policy-issue-brief/the-hyde-amendment-and-coverage-for-abortion-services-under-medicaid-in-the-post-roe-era/. Published March 14, 2024. Accessed February 4, 2025.
7. World Health Organization (WHO). Abortion care guideline. Chapter 3; Section 3.4 Abortion. https://www.who.int/publications/i/item/9789240039483. Published March 8, 2022. Accessed February 4, 2025.

Important Reminder

This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions, and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment, or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees, and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

©2018 Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene® and Centene Corporation® are registered trademarks exclusively owned by Centene Corporation.

Page 9 of 9