Preterm Early-Term Deliveries Form

MEDICAL COVERAGE POLICY SERVICE: Preterm and Early Term Deliveries Policy Number: 216 Effective Date: 08/01/2025 Last Review: 06/09/2025 Next Review: 06/09/2026 Page 1 of 6 Important note: Unless otherwise indicated, medical policies will apply to all lines of business. Medical necessity as defined by this policy does not ensure the benefit is covered. This medical policy does not replace existing federal or state rules and regulations for the applicable service or supply. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan documents. See the member plan specific benefit plan document for a complete description of plan benefits, exclusions, limitations, and conditions of coverage. In the event of a discrepancy, the plan document always supersedes the information in this policy. SERVICE: Preterm and Early-Term Deliveries PRIOR AUTHORIZATION: Not required
Health Services Department (HSD) reviews each hospitalization from the time of patient admission or observation through discharge and follow-up care. Each hospitalization day must meet InterQual® and/or BSWHP internally developed medical necessity criteria, as determined by Plan Medical Director(s.) POLICY: Please review the plan’s EOC (Evidence of Coverage) or Summary Plan Description (SPD) for coverage details. Note: Unless otherwise indicated (see below), this policy will apply to all lines of business. For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual | TMHP (TMPPM). If there are no applicable criteria to guide medical necessity decision making in the TMPPM, use the criteria set forth below. TMPPM 4.1.2 Vaginal and Cesarean Deliveries One of the following modifiers must be billed with the procedure codes indicated above for vaginal and cesarean deliveries:
Modifiers U1 Prior to 39 Weeks and Medically Necessary U2 39 weeks or later U3 Prior to 39 weeks and not Medically Necessary Claims will deny if submitted for a delivery prior to 39 weeks of gestation and not medically necessary, or for a delivery service with no modifier. Claims will deny or recoupment will occur for associated claims for deliveries that are performed prior to 39 weeks and are determined to be not medically necessary including:  Claims for the provider performing the vaginal or Cesarean delivery  Inpatient and outpatient hospital claims inclusive of the delivery, planned Cesarean section,

MEDICAL COVERAGE POLICY SERVICE: Preterm and Early Term Deliveries Policy Number: 216 Effective Date: 08/01/2025 Last Review: 06/09/2025 Next Review: 06/09/2026 Page 2 of 6 induction with vaginal delivery or failed induction with subsequent Cesarean section  Birthing center claims inclusive of induction with vaginal delivery  Claims for medical or surgical admission, including ICU, due to the complications of the delivery for the mother 4.1.3 Elective Deliveries Prior to 39 Weeks Texas Medicaid restricts any Cesarean section, labor induction, or any delivery following labor induction to one of the following criteria: • Gestational age of the fetus should be determined to be at least 39 weeks • When the delivery occurs prior to 39 weeks, maternal and/or fetal conditions must dictate medical necessity for the delivery BSWHP may not consider obstetric deliveries via cesarean section or labor induction prior to 39 weeks medically necessary unless criteria are met: Cesarean section or labor induction at >34 weeks but <39 weeks may be medically necessary if a medical condition exists as listed in the table below (from American College of Obstetricians and Gynecologists Committee on Obstetric Practice; Committee Opinion Number 764 [February 2019] and Number 831 [July 2021]). Non-spontaneous deliveries at gestational ages less than recommended in the table below will be reviewed for medical necessity. Medical documentation supporting such a decision should be in the clinical record. Recommendations for the Timing of Delivery When Conditions Complicate Pregnancy Placental / Uterine Conditions Suggested specific Timing Placenta previa (no other complications) 36 0/7 – 37 6/7 wks gest Suspected accreta, increta, or percreta (no other complications) 34 0/7 – 35 6/7 wks gest Vasa previa 34 0/7 – 37 0/7 wks gest Prior classical cesarean 36 0/7 – 37 0/7 wks gest Prior myomectomy requiring cesarean delivery 37 0/7 – 38 6/7 wks gest Previous uterine rupture 36 0/7 – 37 0/7 wks gest Fetal Conditions Oligohydramnios (isolated or otherwise uncomplicated [deepest vertical pocket less than 2 cm]) 36 0/7 – 37 6/7 wks gest or at diagnosis if diagnosed later Polyhydramnios (mild, idiopathic, no other complication 39 0/7 – 40 6/7 wks gest Growth restriction (singleton)

MEDICAL COVERAGE POLICY SERVICE: Preterm and Early Term Deliveries Policy Number: 216 Effective Date: 08/01/2025 Last Review: 06/09/2025 Next Review: 06/09/2026 Page 3 of 6 Otherwise uncomplicated, no concurrent findings and EFW 3- 10% 38 0/7 – 39 0/7 wks gest Otherwise uncomplicated, no concurrent findings and EFW < 3% 37 0/7 wks gest or at diagnosis if later Abnormal umbilical artery dopplers: elevated impedance to flow, [e.g., S/D ratio, pulsatility index, resistance index, > 95% for gest age] with end diastolic flow still present Consider at 33 0/7 wks gest or at diagnosis if later Abnormal umbilical artery dopplers: absent end diastolic flow 33 0/7-3 0/7 wks of gestation or at diagnosis if later Abnormal umbilical artery dopplers: reversed end diastolic flow 30 0/7-32 0/7 wks gest or at diagnosis if later Concurrent conditions (oligohydramnios, maternal co-morbidity [e.g., preeclampsia, chronic hypertension]) 34 0/7 – 37 6/7 wks gest Multiple gestations – uncomplicated Di-Di twins 38 0/7 – 38 6/7 wks gest Mo-Di twins 34 0/7 – 37 6/7 wks gest Mo-Mo twins 32 0/7 – 34 0/7 wks gest Triplet and higher order Individualized Multiple gestations – complicated Di-Di twins with isolated fetal growth restriction 36 0/7 – 37 6/7 wks gest Di-Di twins with concurrent condition Individualized Mo-Di twins with isolated fetal growth restriction 32 0/7 – 34 6/7 wks gest Alloimmunization At-risk pregnancy not requiring intrauterine transfusion 37 0/7 – 38 6/7 wks gest Requiring intrauterine transfusion Individualized Non-reassuring fetal testing (from MOD reference 3) Intrauterine fetal demise Maternal Conditions Hypertensive disorders of pregnancy Chronic hypertension: isolated, uncomplicated, controlled, not requiring medications 38 0/7 – 39 6/7 wks gest Chronic hypertension: isolated, uncomplicated, controlled on medications 37 0/7 – 39 6/7 wks gest Chronic hypertension: difficult to control (requiring frequent medication adjustments) 36 0/7 – 37 6/7 wks gest Gestational hypertension – without severe-range BP 37 0/7 wks gest or at diagnosis if diagnosed later Gestational hypertension – with severe-range BP 34 0/7 wks gest or at diagnosis if later Preeclampsia – without severe features 37 0/7 wks gest or at diagnosis if later

MEDICAL COVERAGE POLICY SERVICE: Preterm and Early Term Deliveries Policy Number: 216 Effective Date: 08/01/2025 Last Review: 06/09/2025 Next Review: 06/09/2026 Page 4 of 6 Preeclampsia with severe features, stable maternal and fetal conditions, after fetal viability (includes superimposed) 34 0/7 wks gest or at diagnosis if later Preeclampsia with severe features, unstable or complicated, after fetal viability (includes superimposed and HELLP) Soon after maternal stabilization Preeclampsia with severe features, before viability Soon after maternal stabilization Cholestasis (Intrahepatic cholestasis of pregnancy) 36 0/7 – 39 0/7 wks gest or at diagnosis if diagnosed later Diabetes Pregestational well-controlled (no other complications) 39 0/7 – 39 6/7 wks gest Pregestational with vascular complications, poor glucose control, prior stillbirth 36 0/7 – 38 6/7 wks gest Gestational – well-controlled on diet and exercise 39 0/7 – 40 6/7 wks gest Gestational – well-controlled on medications 39 0/7 – 39 6/7 wks gest Gestational – poorly-controlled Individualized HIV Intact membranes and viral load >1,000 copies/mL 38 0/7 wks gest Viral load 1,000 copies/ml with antiretroviral therapy 39 0/7 wks gest or later Obstetric issues PPROM 34 0/7-36 6/7 wks gest or at diagnosis if diagnosed later PROM (37 0/7 weeks of gestation and beyond) Generally, at diagnosis Previous stillbirth Individualized Abbreviations: Di-Di, dichorionic-diamniotic; Mo-Di, monochorionic-diamniotic; PPROM, preterm premature rupture of membranes. This list is not meant to be all-inclusive, but represents commonly encountered clinical indications.
BACKGROUND: Studies have found that more than a third of babies were delivered by cesarean without a medical necessity prior to 39 weeks. Infants born at 38 weeks had a 50% greater chance of being sufficiently ill to require neonatal ICU care, and those delivered at 37 weeks were twice as likely to be admitted to the neonatal ICU. Infants born between 39- and 40-weeks gestation were at the lowest risk for neonatal problems. Not only does this result in a better outcome for the newborn infant but studies have shown that healthcare costs are reduced when elective deliveries at less than 39 weeks are eliminated. MANDATES: None

MEDICAL COVERAGE POLICY SERVICE: Preterm and Early Term Deliveries Policy Number: 216 Effective Date: 08/01/2025 Last Review: 06/09/2025 Next Review: 06/09/2026 Page 5 of 6 CODES: Important note: Due to the wide range of applicable diagnosis codes and potential changes to codes, an inclusive list may not be presented, but the following codes may apply. Inclusion of a code in this section does not guarantee that it will be reimbursed, and patient must meet the criteria set forth in the policy language. CPT Codes 59409, 59410, 59514, 59515, 59612, 59614, 59620, or 59622 Requires modifier: U1 - Medically necessary delivery prior to 39 weeks of gestation U2 - Delivery at 39 weeks of gestation or later U3 - Non-medically necessary delivery prior to 39 weeks of gestation CPT Not Covered ICD10 codes ICD10 Not covered POLICY HISTORY: Status Date Action New 09/24/2015 New policy Reviewed 09/29/2016 No changes Reviewed 09/19/2017 No changes Reviewed 08/14/2018 Minor changes to wording Updated 10/17/2019 Added cholestasis of pregnancy. Added Medicaid language. Updated 11/19/2020 Updated to align with latest ACOG information. Updated 12/23/2021 Updated to align with latest ACOG information. Reviewed 12/01/2022 No changes Updated 01/26/2023 Minor updated recommended by reviewer Reviewed 01/02/2024 Added details from referenced tables. Formatting changes, added hyperlink to TMPPM, beginning and ending note sections updated to align with CMS requirements and business entity changes. Reviewed 6/10/2024 Corrected the “For Medicaid Plans” section to utilize this Medical Policy if TMPPM does not have medical necessity guidance. Reviewed 06/09/2025 Added “HSD reviews each hospitalization from the time of patient admission or observation through discharge and follow-up care. Each hospitalization day must meet InterQual® and/or BSWHP internally developed medical necessity criteria, as determined by Plan Medical Director(s”; Updated “Medicaid Plans and Timing of Deliveries” Table

MEDICAL COVERAGE POLICY SERVICE: Preterm and Early Term Deliveries Policy Number: 216 Effective Date: 08/01/2025 Last Review: 06/09/2025 Next Review: 06/09/2026 Page 6 of 6 REFERENCES: The following scientific references were utilized in the formulation of this medical policy. BSWHP will continue to review clinical evidence related to this policy and may modify it at a later date based upon the evolution of the published clinical evidence. Should additional scientific studies become available and they are not included in the list, please forward the reference(s) to BSWHP so the information can be reviewed by the Medical Coverage Policy Committee (MCPC) and the Quality Improvement Committee (QIC) to determine if a modification of the policy is in order.

1. Spong CY, Mercer BM, D’Alton M, Kilpatrick S, Blackwell S, Saade G. Timing of indicated late-preterm and early term birth. Obstet Gynecol 2011;118:323–33.
2. Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, and Kowalewski L. Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #08-85012 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; First edition published by March of Dimes, July 2010.
3. Lindor KD, Lee RH. Intrahepatic cholestasis of pregnancy. UpToDate. Accessed 10/14/2019.
4. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL Vol 2: GYNECOLOGICAL, OBSTETRICS, AND FAMILY PLANNING TITLE XIX SERVICES HANDBOOK: Section 4.1.2 Vaginal and Cesarean Deliveries (latest version Nov 2023) and 4.1.3 Elective Deliveries Prior to 39 Weeks
5. The American College of Obstetricians and Gynecologists Committee on Obstetric Practice The Society forTerm Deliveries. February 2019.
6. Medically Indicated Late-Preterm and Early-Term Deliveries: ACOG Committee Opinion, Number 831. Obstet Gynecol 2021 Jul 1;138(1):e35-e39. PMID: 34259491 DOI: 10.1097/AOG.0000000000004447 Note: Health Maintenance Organization (HMO) products are offered through Scott and White Health Plan dba Baylor Scott & White Health Plan, and Scott & White Care Plans dba Baylor Scott & White Care Plan. Insured PPO and EPO products are offered through Baylor Scott & White Insurance Company. Scott and White Health Plan dba Baylor Scott & White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans. Baylor Scott & White Care Plan and Baylor Scott & White Insurance Company are wholly owned subsidiaries of Scott and White Health Plan. These companies are referred to collectively in this document as Baylor Scott & White Health Plan.
   RightCare STAR Medicaid is offered through Scott and White Health Plan in the Central Texas Medicaid Rural Service Area (MRSA); FirstCare STAR is offered through SHA LLC dba FirstCare Health Plans (FirstCare) in the Lubbock and West MRSAs; and FirstCare CHIP is offered through FirstCare in the Lubbock Service Area.