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HumanaCommercial Clinical Policy

Humana Recurrent Pregnancy Loss Form


Recurrent Pregnancy Loss Evaluation

Notes: State mandates for recurrent pregnancy loss may override this policy. Refer to the member's pharmacy benefit for medication coverage. Evaluation methods covered include measurements of certain antibodies, imaging tests for anatomical abnormalities, and thyroid function tests.

Indications

(668850) Has the patient experienced two or more consecutive miscarriages of clinically recognized pregnancies documented by ultrasonography or histopathologic examination? 

Antenatal Transabdominal Cervical Cerclage

Notes: Antenatal transabdominal cervical cerclage is covered under specific conditions such as anatomical limitations or a prior failed transvaginal cerclage.

Indications

(668851) Is the cerclage being performed for cervical insufficiency during a singleton pregnancy? 
(668852) Are there anatomical limitations to transvaginal cerclage or a prior failed transvaginal cerclage? 

Contraindications

(668853) Are there any contraindications present for transabdominal cervical cerclage? 

Antenatal Transvaginal Cervical Cerclage

Notes: Antenatal transvaginal cervical cerclage is covered in the absence of contraindications.

Indications

(668854) Is the cerclage being performed for cervical insufficiency during a singleton pregnancy? 

YesNoN/A
YesNoN/A

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Effective Date

03/23/2023

Last Reviewed

NA

Original Document

  Reference



Recurrent Pregnancy Loss

Medical Coverage Policy

Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0559-007

Change Summary:

Updated Description, Coverage Determination, Coverage Limitations, References

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Disclaimer

Description

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