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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 can not feel their contractions.

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

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

Reichmann (2008) stated that the current paradigm in obstetrics has shifted toward evidence-based medicine, and yet in clinical practice physicians continue to use interventions for which there exists no credible evidence.  The author examined the United States Food and Drug Administration (FDA) status of home uterine activity monitoring (HUAM) and the published clinical trials examining HUAM for the management of current preterm labor.  The use of HUAM was introduced into clinical practice and heavily marketed without benefit of scientific rigor.  Gradually, HUAM use migrated primarily for patients diagnosed (or mis-diagnosed) with preterm labor in the current pregnancy who are stabilized and sent home with or without a tocolytic.  This clinical intervention has not been cleared by the FDA, has virtually no scientific support, and constitutes a gross deviation from evidence-based medicine.  As obstetricians accept the role of medical evidence steering clinical practice, HUAM clearly has no clinical value and therefore should not be used to manage patients outside of a randomized controlled clinical trial.

In a Cochrane review, Urquhart et al (2012) examined if HUAM is effective in improving the outcomes for women and their infants considered to be at high-risk of preterm birth, when compared with conventional or other care packages that do not include HUAM.  These investigators searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 30, 2011), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to November 30, 2011), EMBASE (1974 to November 30, 2011), CINAHL (1982 to November 30, 2011) and scanned reference lists of retrieved studies.  Randomized control trials of HUAM, with or without patient education programs, for women at risk for preterm birth, in comparison to the same care package without HUAM were selected for analysis.  Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias.  Data were checked for accuracy.  These researchers did not attempt to contact authors to resolve queries.  There were 15 included studies (total number of enrolled participants 6,008); 13 studies contributed data.  Women using HUAM were less likely to experience preterm birth at less than 34 weeks (risk ratio (RR) 0.78; 95 % confidence interval (CI): 0.62 to 0.99; 3 studies, n = 1,596; fixed-effect analysis).  However, this significant difference was not evident when the authors carried out a sensitivity analysis, restricting the analysis to studies at low-risk of bias based on study quality (RR 0.75; 95 % CI: 0.57 to 1.00, 1 study, 1,292 women).  There was no significant difference in the rate of perinatal mortality (RR 1.22; 95 % CI: 0.86 to 1.72; 2 studies, n = 2,589).  There was no significant difference in the number of preterm births at less than 37 weeks (average RR 0.85; CI: 0.72 to 1.01; 8 studies, n = 4,834; random effects, T(2) = 0.03, I(2) = 68 %).  Infants born to women using HUAM were less likely to be admitted to neonatal intensive care unit (average RR 0.77; 95 % CI: 0.62 to 0.96; 5 studies, n = 2,367; random-effects, T(2) = 0.02, I(2) = 32 %).  Although this difference was not statistically significant when only high-quality studies were included (RR 0.86; 95 % CI: 0.74 to 1.01; 1 study, n = 1,292).  Women using HUAM made more unscheduled antenatal visits (mean difference (MD) 0.49; 95 % CI: 0.39 to 0.62; 2 studies, n = 2,807).  Women using HUAM were also more likely to have prophylactic tocolytic drug therapy (average RR 1.21; 95 % CI: 1.01 to 1.45; 7 studies, n = 4,316; random-effects. T(2) = 0.03, I(2) = 62 %); but this difference was no longer significant when the analysis was restricted to high-quality studies (average RR 1.22; 95 % CI: 0.90 to 1.65, 3 studies, n = 3,749,random effects, T(2) = 0.05, I(2) = 76 %).  One small study reported that the HUAM group spent fewer days in hospital antenatally.  No data on maternal anxiety or acceptability were found.  The authors concluded that HUAM may result in fewer admissions to a neonatal intensive care unit but more unscheduled antenatal visits and tocolytic treatment.  There is no impact on maternal and perinatal outcomes such as perinatal mortality or incidence of preterm birth.

 
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
V91.00 - V91.09 Twin gestation placenta status
V91.10 - V91.19 Triplet gestation placenta status
V91.20 - V91.29 Quadruplet gestation placenta status
V91.90 - V91.99 Other specified multiple gestation placenta status


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.
  24. Reichmann JP. Home uterine activity monitoring: The role of medical evidence. Obstet Gynecol. 2008;112(2 Pt 1):325-327.
  25. Rittenberg C, Newman RB, Istwan NB, et al. Preterm birth prevention by 17 alpha-hydroxyprogesterone caproate vs. daily nursing surveillance. J Reprod Med. 2009;54(2):47-52.
  26. Urquhart C, Currell R, Harlow F, Callow L. Home uterine monitoring for detecting preterm labour. Cochrane Database Syst Rev. 2012;(5):CD006172.


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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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