Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut LAB.00029 Rupture of Membranes Testing in Pregnancy Form

Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



This document addresses testing for suspected rupture of membranes (ROM) with test kits, such as the AmniSure® ROM test, which detects placental alpha-1 microglobulin (PAMG-1), a protein marker of amniotic fluid in vaginal secretions; the ROM Plus® Fetal Membrane Rupture test, which tests both placental protein 12 (PP12) and alpha-fetoprotein (AFP); and the Actim® PROM test, which tests for insulin-like growth factor binding protein 1 (IGFBP-1).

Position Statement

Not Medically Necessary:

Evaluation of cervicovaginal fluid for specific amniotic fluid protein(s), (for example, placental alpha microglobulin-1 [PAMG-1], placental protein 12 [PP12], alpha-fetoprotein), is considered not medically necessary for all indications, including detection of preterm rupture of membranes.