# Clinical Policy: Ultrasound in Pregnancy
Reference Number: CP.MP.38  
Date of Last Revision: 03/25  

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

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

## Description  
This policy outlines the medical necessity criteria for ultrasound use in pregnancy. Ultrasound is the most common fetal imaging tool used today. Ultrasound is accurate at determining gestational age, fetal number, viability, and placental location and is necessary for many diagnostic purposes in obstetrics. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered. Ultrasound exams should be conducted only when indicated and must be appropriately documented.  

## Policy/Criteria  
It is the policy of health plans affiliated with Centene Corporation® that the following ultrasounds during pregnancy are considered **medically necessary** when the following conditions are met:  

I. 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.  

II. 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.  

    An additional standard second or third trimester ultrasound is considered **medically necessary** if a new provider is taking over care.  

III. One detailed anatomic ultrasound (76811) is allowed per pregnancy when performed to evaluate for suspected anomalies 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 from Table 4 below.  

    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.  

Clinical Policy

Ultrasound in Pregnancy

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Clinical Policy

Ultrasound in Pregnancy

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Clinical Policy

Ultrasound in Pregnancy

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Ultrasound in Pregnancy

Reviews, Revisions, and Approvals

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Clinical Policy

Ultrasound in Pregnancy

Reviews, Revisions, and Approvals

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Clinical Policy

Ultrasound in Pregnancy

Reviews, Revisions, and Approvals

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Clinical Policy

Ultrasound in Pregnancy

Reviews, Revisions, and Approvals

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

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Clinical Policy

Ultrasound in Pregnancy

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 of 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

Clinical Policy Ultrasound in Pregnancy 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.

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