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Clinical Policy Bulletin:
Home Uterine Activity Monitoring
Number: 0127


Policy

Aetna considers home uterine activity monitoring (HUAM) experimental and investigational. In its discretion, Aetna may consider HUAM medically necessary upon review of each circumstance and consideration of any of the following criteria:

  1. Women with complicated pregnancies who cannot feel their contractions.

    HUAM may be considered medically necessary on an individual case exception basis for women who cannot feel their contractions and have any of the following complications:

    1. Triplets, quadruplets, or greater multiple gestations (however, HUAM is not considered medically necessary in twin gestations unless other extenuating circumstances exist); or
    2. Incompetent cervix (as documented by need for cerclage or signs of cervical incompetence (funneling on valsalva, silent shortening); or

    3. Presence of risk factors that increase risk of preterm birth: placenta previa with hemorrhage; history of classical caesarean section or deep myomectomy with contractions/cervical change in index pregnancy, such that woman is not able to safely tolerate contractions; or

  2. Women with preterm labor, where conventional methods to arrest progression of preterm labor have failed; or

  3. Women with a positive fetal fibronectin test and progressive cervical changes (with cervical length less than 2.5 cm documented by vaginal probe ultrasound) despite treatment with multiple tocolytics.



Background

Large randomized controlled trials have demonstrated that the use of a home uterine monitor is not associated with a decrease in the incidence of preterm birth. This analysis is supported by policy statements by the American College of Obstetricians and Gynecologists (1997; 2001; 2003) and the U.S. Preventive Services Taskforce (1996). An evidence report prepared for the Agency for Healthcare Research and Quality (AHRQ) (2000) concluded that "home uterine activity monitoring was found to confer no maternal or fetal/neonatal benefits."
 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes not covered for indications listed in the CPB:
99500
Other CPT codes related to the CPB:
82731
HCPCS codes not covered for indications listed in the CPB:
S9001 Home uterine monitor with or without associated nursing services
Other HCPCS codes related to the CPB:
S9208 - S9214 Home management of preterm labor, preterm rupture of membranes (PROM), gestational hypertension, postpartum hypertension, preeclampsia, or gestational diabetes, including administrative services, professional pharmacy services, care coordination, and all necessary supplies or equipment (drugs and nursing visits coded separately), per diem (do not use this code with any home infusion per diem code)
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
641.13 Hemorrhage from placenta previa, antepartum condition or complication
644.03 Threaten premature labor, antepartum condition or complication
651.13 Triplet pregnancy, antepartum condition or complication
651.23 Quadruplet pregnancy, antepartum condition or complication
651.43 Triplet pregnancy with fetal loss and retention of one or more fetus(es), antepartum condition or complication
651.53 Quadruplet pregnancy with fetal loss and retention of one or more fetus(es), antepartum condition or complication
651.63 Other multiple pregnancy with fetal loss and retention of one or more fetus(es), antepartum condition or complication
654.23 Previous cesarean delivery, antepartum condition or complication
654.53 Cervical incompetence, antepartum condition or complication
V23.41 Supervision of pregnancy with history of pre-term labor


The above policy is based on the following references:
  1. American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetric Practice. Home uterine activity monitoring. ACOG Committee Opinion No. 172. Washington, DC: ACOG; May 1996, reaffirmed 1997.
  2. U.S. Preventive Services Task Force. Home uterine activity monitoring for preterm labor. Review article. JAMA. 1993;270(3):371-376.
  3. U.S. Preventive Services Task Force. Home uterine activity monitoring. In: Guide to Clinical Preventive Services. 2nd ed. Philadelphia, PA: Williams & Wilkins; 1996:443-447.
  4. Agency for Health Care Policy and Research (AHCPR). Health technology review of home uterine monitoring. AHCPR Publication No. 92-0064. Rockville, MD: AHCPR; 1992.
  5. Barrett I, Bocking A. Management of twin pregnancies (part 1). Society of Obstetricians and Gynaecologists of Canada (SOGC) Consensus Statement. J SOGC. 2000;91:5-15.
  6. Berkman, ND, Thorp, JM Jr, Hartmann, KE, et al. Management of preterm labor. Volume 1: Evidence report and appendices. Volume 2: Evidence tables
    Evidence Report/Technology Assessment No. 18. Prepared by Research Triangle Institute under Contract No. 290-97-0011. AHRQ Publication Nos. 01-E020 and 01-E021. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2000.
  7. Mulrow CD, Chiquette E, Ferrer RL, et al. Management of chronic hypertension during pregnancy. Evidence Report/Technology Assessment No. 14. Prepared by the San Antonio Evidence-based Practice Center based at the University of Texas Health Science Center at San Antonio under Contract No. 290-97-0012. AHRQ Publication No. 00-E011. Rockville, MD: Agency for Heathcare Research and Quality (AHRQ); August 2000.
  8. Myers ER, Blumrick R, Christian AL, et al. Management of prolonged pregnancy. Evidence Report/Technology Assessment No. 53. Prepared by Duke Evidence-Based Practice Center, Durham, NC, under Contract No. 290-97-0014. AHRQ Publication No. 02-E018. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); May 2002.
  9. American College of Obstetricians and Gynecologists (ACOG). Assessment of risk factors for preterm birth. ACOG Practice Bulletin No. 31. Washington, DC: ACOG; October 2001.
  10. Maxwell CV, Amankwah KS. Alternative approaches to preterm labor. Semin Perinatol. 2001;25(5):310-315.
  11. Mauldin JG, Newman RB. Preterm birth risk assessment. Semin Perinatol. 2001;25(4):215-222.
  12. Kalchbrenner MA. Clinical review of home uterine activity monitoring (HUAM). J Am Osteopath Assoc. 2001;101(2 Suppl):S18-S24.
  13. Iams JD, Newman RB, Thom EA, et al. Frequency of uterine contractions and the risk of spontaneous preterm delivery. N Engl J Med. 2002;346(4):250-255.
  14. Goldenberg RL. The management of preterm labor. Obstet Gynecol. 2002;100(5 Pt 1):1020-1037.
  15. Institute for Clinical Systems Improvement (ICSI). Home uterine activity monitoring for detection of preterm labor. Technology Assessment. Bloomington, MN: ICSI; 2002.
  16. L'Agence Nationale d'Accreditation d'Evaluation en Sante (ANAES). Fetal heart rate monitoring protocols during normal labour: Indications and benefits [summary]. Paris, France: ANAES; 2002.
  17. American College of Obstetricians and Gynecologists (ACOG), Committee on Practice Bulletins. Management of preterm labor. ACOG Practice Bulletin No. 43. Washington, DC: ACOG; May 2003.
  18. Cleary-Goldman J, Morgan MA, Robinson JN, et al. Multiple pregnancy: Knowledge and practice patterns of obstetricians and gynecologists. Obstet Gynecol. 2004;104(2):232-237.
  19. California Technology Assessment Forum (CTAF). Home uterine activity monitoring for secondary and tertiary prevention of preterm birth. Technology Assessment. San Francisco, CA: California Technology Assessment Forum; June 12, 2002. Available at: http://ctaf.org/ass/viewfull.ctaf?id=6048341323. Accessed March 4, 2005.
  20. Newman RB. Uterine contraction assessment. Obstet Gynecol Clin North Am. 2005;32(3):341-367.
  21. Krupa FG, Faltin D, Cecatti JG, et al. Predictors of preterm birth. Int J Gynaecol Obstet. 2006;94(1):5-11.
  22. Urquhart C, Currell R, Callow E, Harlow F. Home uterine monitoring for detecting preterm labour (Protocol for Cochrane Review). Cochrane Database Syst Rev. 2006;(4):CD006172.
  23. Krampl E, Klein K. Prematurity in multiple pregnancies. Gynakol Geburtshilfliche Rundsch. 2007;47(2):64-69.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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