Anthem Blue Cross Connecticut RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care Form

This document addresses the use of three-dimensional (3-D), four-dimensional (4-D) and five-dimensional (5-D) fetal ultrasound in maternity care and does not apply to ultrasound performed for non-pregnancy related conditions. Fetal ultrasound is a test performed during pregnancy, either to assess the gestational age or to evaluate fetal size, position, heartbeat, congenital malformations, suspected multiple fetuses or placental abnormalities. Two-dimensional (2-D) ultrasound is most commonly used. The 3-D and 4-D ultrasounds create computer-generated images viewed on a video monitor that provide more detail and almost life-like images of the fetus. 5-D ultrasounds automate the process of reconstructing 3-D images to create 2-D images.

Note: Please see the following related document for additional information:

• CG-MED-42 Maternity Ultrasound in the Outpatient Setting

Position Statement

Investigational and Not Medically Necessary:

The use of 3-D, 4-D or 5-D fetal ultrasound is considered investigational and not medically necessary in all cases.