Anthem Blue Cross Connecticut SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations Form

This document addresses the use of surgical techniques to correct or treat fetal malformations in utero. This document does not address surgery to correct placental or uterine abnormalities including, but not limited to, amnioreduction or laser coagulation therapy to address interfetal transfusion syndrome.

Position Statement

Medically Necessary:

1. Fetal surgery is considered medically necessary for vesico-amniotic shunting as a treatment of urinary tract obstruction in fetuses when all the following conditions are met:
   1. Bilateral obstruction; and
   2. Evidence of progressive oligohydramnios; and
   3. Adequate renal function reserves; and
   4. No other lethal or chromosomal abnormalities.
2. Fetal surgery is considered medically necessary for fetuses at 32 weeks gestation, or less, with evidence of fetal hydrops, placentamegaly, or the beginnings of severe pre-eclampsia (for example, the maternal mirror syndrome) in the mother, for the following procedures:
   1. Either open or in-utero resection of malformed pulmonary tissue or placement of a thoraco-amniotic shunt as a treatment of either congenital cystic adenomatoid malformation or extralobar pulmonary sequestration; or
   2. In-utero removal of sacrococcygeal teratoma.
3. Fetal surgery is considered medically necessary for repair of myelomeningocele when all the following conditions are met:
   1. Singleton pregnancy; and
   2. Myelomeningocele with the upper boundary of the lesion located between T1 and S1; and
   3. Evidence of hindbrain herniation; and
   4. Gestational age of 19.0 to 25.9 weeks; and
   5. Normal fetal karyotype; and
   6. Absence of all of the following:
      1. Fetal anomaly unrelated to the myelomeningocele; and
      2. Severe fetal kyphosis; and
      3. Short cervix (less than or equal to 15 mm); and
      4. Previous pre-term birth; and
      5. Placental abruption; and
      6. Maternal Body Mass Index (BMI) greater than or equal to 35 kg/m²; and
      7. Contraindications to surgery, including but not limited to previous hysterotomy in the active (upper) uterine segment.
4. Fetal surgery to perform fetoscopic endoluminal tracheal occlusion (FETO) is considered medically necessary in fetuses with pulmonary hypoplasia due to severe isolated congenital diaphragmatic hernia (CDH) when all the following conditions are met:
   1. Singleton pregnancy; and
   2. Gestational age less than 29 weeks and 6 days; and
   3. Congenital diaphragmatic hernia on the left side with no other major structural or chromosomal defects; and
   4. Severe hypoplasia, defined as a quotient of the observed-to-expected lung-to-head ratios of less than 25.0%, irrespective of liver position; and
   5. Absence of all of the following:
      1. Maternal contraindications to fetoscopic surgery or severe medical conditions that would make fetal intervention risk full; and
      2. Technical limitations precluding fetoscopic surgery including, but not limited to, severe obesity (maternal BMI greater than or equal to 35 kg/m²), or uterine fibroids; and
      3. Short cervix (less than or equal to 15 mm); and
      4. Müllerian anomalies; and
      5. Placenta previa.

Investigational and Not Medically Necessary:

1. Fetal surgery is considered investigational and not medically necessary for the conditions indicated above when medically necessary criteria are not met.
2. All other applications of fetal surgery including, but not limited to, aqueductal stenosis are considered investigational and not medically necessary.