Prior authorization request form Form

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Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Background Fetal surgery (also referred to as in-utero or prenatal surgery) is a complex surgical intervention performed on the developing fetus in-utero, using open or minimally invasive techniques, to correct fetal abnormalities that interfere with organ development and fetal survival.
Guideline Fetal surgery is considered medically necessary for any of the following:  Amniotic band syndrome (ABS)  Bladder outlet obstruction (BOO)  Congenital diaphragmatic hernia (CDH)  Congenital high airway obstruction syndrome (CHAOS)  Congenital lung masses/malformations, e.g.:  Bronchial atresia  Bronchogenic cysts  Bronchopulmonary sequestration (BPS) (aka lung or pulmonary sequestration)  Congenital pulmonary airway malformation (CPAM) (previously known as congenital cystic adenomatoid malformation [CCAM])

Page 2 of 6  Extralobar pulmonary sequestration (EPS)  Fetal cystic hygroma  Fetal renal failure (FRF)  Hydronephrosis  Mediastinal teratoma  Myelomeningocele (spina bifida)  Pleural Effusion
 Sacrococcygeal Teratoma (SCT)
 Twin anemia-polycythemia sequence (TAPS)  Twin reversed arterial perfusion (TRAP)  Twin-Twin Transfusion Syndrome (TTTS)  Urinary Tract Obstruction (UTO) (aka obstructive uropathy, e.g., congenital posterior urethral valves)  Fetal anemia Limitations/Exclusions The following indications, considered experimental, investigational or unproven will be reviewed on a case-by-case basis upon request (list not all-inclusive):  Aqueductal stenosis (i.e., hydrocephalus)  Cleft lip and/or cleft palate
 Congenital heart defects/disease (e.g., aortic stenosis, mitral valve dysplasia/regurgitation, pericardial teratoma)  Gastroschisis  Hydronephrosis The following in utero interventions, considered experimental, investigational or unproven, will be reviewed on a case-by-case basis upon request (list not all-inclusive):  Aortic or pulmonary balloon valvuloplasty  Arial needle septoplasty  Endoscopic approach (i.e., fetoscopic cystoscopy) for the treatment of lower UTO  Fetoscopic laser ablation for type 2 vasa previa  In-utero gene therapy
 In-utero hematopoietic stem-cell transplantation for stem-cell-related diseases
 Laser, thermocoagulation or radiofrequency ablation techniques for the treatment of sacrococcygeal teratoma  Percutaneous sclerotherapy  Shunting for the treatment of fetal cerebral ventriculomegaly
Procedure Codes
59001 Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance) 59072 Fetal umbilical cord occlusion, including ultrasound guidance 59074 Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance

Page 3 of 6 59076 Fetal shunt placement, including ultrasound guidance 59897 Unlisted fetal invasive procedure, including ultrasound guidance, when performed S2401 Repair, urinary tract obstruction in the fetus, procedure performed in utero S2402 Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero S2403 Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero S2404 Repair, myelomeningocele in the fetus, procedure performed in utero S2405 Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero S2409 Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified S2411 Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome

ICD-10 Diagnoses D18.1 Lymphangioma, any site D48.0 Neoplasm of uncertain behavior of bone and articular cartilage O30.021 Conjoined twin pregnancy, first trimester O30.022 Conjoined twin pregnancy, second trimester O30.23 Conjoined twin pregnancy, third trimester O30.029 Conjoined twin pregnancy, unspecified trimester O33.7XX0 Maternal care for disproportion due to other fetal deformities, not applicable or unspecified O33.7XX1 Maternal care for disproportion due to other fetal deformities, fetus 1 O33.7XX2 Maternal care for disproportion due to other fetal deformities, fetus 2 O33.7XX3 Maternal care for disproportion due to other fetal deformities, fetus 3 O33.7XX4 Maternal care for disproportion due to other fetal deformities, fetus 4 O33.7XX5 Maternal care for disproportion due to other fetal deformities, fetus 5 O33.7XX9 Maternal care for disproportion due to other fetal deformities, other fetus O36.8210 Fetal anemia and thrombocytopenia, first trimester, unsp O36.8211 Fetal anemia and thrombocytopenia, first trimester, fetus 1 O36.8212 Fetal anemia and thrombocytopenia, first trimester, fetus 2 O36.8213 Fetal anemia and thrombocytopenia, first trimester, fetus 3 O36.8214 Fetal anemia and thrombocytopenia, first trimester, fetus 4 O36.8215 Fetal anemia and thrombocytopenia, first trimester, fetus 5 O36.8219 Fetal anemia and thrombocytopenia, first trimester, other O36.8220 Fetal anemia and thrombocytopenia, second trimester, unsp O36.8221 Fetal anemia and thrombocytopenia, second trimester, fetus 1 O36.8222 Fetal anemia and thrombocytopenia, second trimester, fetus 2 O36.8223 Fetal anemia and thrombocytopenia, second trimester, fetus 3

Page 4 of 6 O36.8224 Fetal anemia and thrombocytopenia, second trimester, fetus 4 O36.8225 Fetal anemia and thrombocytopenia, second trimester, fetus 5 O36.8229 Fetal anemia and thrombocytopenia, second trimester, other O36.8230 Fetal anemia and thrombocytopenia, third trimester, unsp O36.8231 Fetal anemia and thrombocytopenia, third trimester, fetus 1 O36.8232 Fetal anemia and thrombocytopenia, third trimester, fetus 2 O36.8233 Fetal anemia and thrombocytopenia, third trimester, fetus 3 O36.8234 Fetal anemia and thrombocytopenia, third trimester, fetus 4 O36.8235 Fetal anemia and thrombocytopenia, third trimester, fetus 5 O36.8239 Fetal anemia and thrombocytopenia, third trimester, other O36.8290 Fetal anemia and thrombocytopenia, unsp trimester, unsp O36.8291 Fetal anemia and thrombocytopenia, unsp trimester, fetus 1 O36.8292 Fetal anemia and thrombocytopenia, unsp trimester, fetus 2 O36.8293 Fetal anemia and thrombocytopenia, unsp trimester, fetus 3 O36.8294 Fetal anemia and thrombocytopenia, unsp trimester, fetus 4 O36.8910 Maternal care for other specified fetal problems, first trimester, not applicable or unspecified O36.8911 Maternal care for other specified fetal problems, first trimester, fetus 1 O36.8912 Maternal care for other specified fetal problems, first trimester, fetus 2 O36.8913 Maternal care for other specified fetal problems, first trimester, fetus 3 O36.8914 Maternal care for other specified fetal problems, first trimester, fetus 4 O36.8915 Maternal care for other specified fetal problems, first trimester, fetus 5 O36.8919 Maternal care for other specified fetal problems, first trimester, other fetus O36.8920 Maternal care for other specified fetal problems, second trimester, not applicable or unspecified O36.8921 Maternal care for other specified fetal problems, second trimester, fetus 1 O36.8922 Maternal care for other specified fetal problems, second trimester, fetus 2 O36.8923 Maternal care for other specified fetal problems, second trimester, fetus 3 O36.8924 Maternal care for other specified fetal problems, second trimester, fetus 4 O36.8925 Maternal care for other specified fetal problems, second trimester, fetus 5 O36.8929 Maternal care for other specified fetal problems, second trimester, other fetus O36.8930 Maternal care for other specified fetal problems, third trimester, not applicable or unspecified O36.8931 Maternal care for other specified fetal problems, third trimester, fetus 1 O36.8932 Maternal care for other specified fetal problems, third trimester, fetus 2 O36.8933 Maternal care for other specified fetal problems, third trimester, fetus 3 O36.8934 Maternal care for other specified fetal problems, third trimester, fetus 4 O36.8935 Maternal care for other specified fetal problems, third trimester, fetus 5 O36.8939 Maternal care for other specified fetal problems, third trimester, other fetus

Page 5 of 6 O36.8990 Maternal care for other specified fetal problems, unspecified trimester, not applicable or unspecified O36.8991 Maternal care for other specified fetal problems, unspecified trimester, fetus 1 O36.8992 Maternal care for other specified fetal problems, unspecified trimester, fetus 2 O36.8993 Maternal care for other specified fetal problems, unspecified trimester, fetus 3 O36.8994 Maternal care for other specified fetal problems, unspecified trimester, fetus 4 O36.8995 Maternal care for other specified fetal problems, unspecified trimester, fetus 5 O36.8999 Maternal care for other specified fetal problems, unspecified trimester, other fetus O43.021 Fetus-to-fetus placental transfusion syndrome, first trimester O43.022 Fetus-to-fetus placental transfusion syndrome, second trimester O43.023 Fetus-to-fetus placental transfusion syndrome, third trimester O43.029 Fetus-to-fetus placental transfusion syndrome, unspecified trimester P02.3 Newborn affected by placental transfusion syndromes P28.89 Other specified respiratory conditions of newborn Q05.0 Cervical spina bifida with hydrocephalus Q05.1 Thoracic spina bifida with hydrocephalus Q05.2 Lumbar spina bifida with hydrocephalus Q05.3 Sacral spina bifida with hydrocephalus Q05.4 Unspecified spina bifida with hydrocephalus Q05.5 Cervical spina bifida without hydrocephalus Q05.6 Thoracic spina bifida without hydrocephalus Q05.7 Lumbar spina bifida without hydrocephalus Q05.8 Sacral spina bifida without hydrocephalus Q05.9 Spina bifida, unspecified Q07.00 Arnold-Chiari syndrome without spina bifida or hydrocephalus Q07.01 Arnold-Chiari syndrome with spina bifida Q07.02 Arnold-Chiari syndrome with hydrocephalus Q07.03 Arnold-Chiari syndrome with spina bifida and hydrocephalus Q07.8 Other specified congenital malformations of nervous system Q07.9 Congenital malformation of nervous system, unspecified Q18.8 Other specified congenital malformations of face and neck Q33.0 Congenital cystic lung Q33.2 Sequestration of lung Q33.3 Agenesis of lung Q33.6 Congenital hypoplasia and dysplasia of lung Q62.31 Congenital ureterocele, orthotopic Q62.32 Cecoureterocele

Page 6 of 6 Q62.39 Other obstructive defects of renal pelvis and ureter Q64.2 Congenital posterior urethral valves Q64.31 Congenital bladder neck obstruction Q64.32 Congenital stricture of urethra Q64.33 Congenital stricture of urinary meatus Q64.39 Other atresia and stenosis of urethra and bladder neck Q89.4 Conjoined twins Q89.8 Other specified congenital malformations R89.7 Abnormal histological findings in specimens from other organs, systems and tissues References Holcomb & Ashcraft’s Pediatric Surgery, 7th Ed., Elsevier Pub. 2020, Chapter on “Fetal Surgery.” Pediatric Surgery, 2nd Ed., Coppola et al Eds., Springer Pub. 2022, Chapter on “Fetal Surgery and Interventions,” pp. 263-272. Patel, et al: Procedural, pregnancy, and short-term outcomes after fetal aortic valvuloplasty, Catheterization and Cardiovascular Interventions, 96(3); 626-632, 2020. Pickard, et al: Fetal Aortic Valvuloplasty for Evolving Hypoplastic Left Heart Syndrome: A Decision Analysis, Circulation, Cardiovascular Quality and Outcomes, 13(4): epub 2020.
Specialty matched clinical peer review. Revision History Company

  DATE

REVISION EmblemHealth Mar. 16, 2026 Added fetal anemia as a covered indication EmblemHealth Feb. 14, 2025 Added fetal cystic hygroma as covered indication EmblemHealth ConnectiCare Dec. 8, 2023 New policy

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