Aetna considers in-office and in-hospital antepartum fetal surveillance with non-stress tests (NST), contraction stress tests (CST), biophysical profile (BPP), modified BPP, and umbilical artery Doppler velocimetry medically necessary according to the American College of Obstetricians and Gynecologists (ACOG) Clinical Guideline on Antepartum Fetal Surveillance.
The following medical necessity guidelines apply:
Antepartum fetal surveillance using NST, CST, BPP, or modified BPP is considered medically necessary for women with risk factors for stillbirth due to utero-placental insufficiency. Accepted guidelines state that fetal testing should not begin until interventions can be undertaken. For most pregnancies at increased risk of stillbirth due to utero-placental insufficiency, testing is considered appropriate beginning at 32 to 34 weeks of gestation. Testing is considered medically necessary beginning at 26 weeks gestation for pregnancies with multiple or particularly worrisome high-risk conditions. Examples of such high-risk conditions include bleeding, chronic or pregnancy-induced hypertension, collagen vascular disease (including anti-phospholipid syndrome), fetal growth restriction, gestational diabetes, impaired renal function, maternal heart disease (New York Heart Association Class III or IV), oligohydramnios, significant isoimmunization, steroid-dependent or poorly controlled asthma (not an all-inclusive list).
If the clinical condition that has prompted testing persists, repeat testing (either weekly or twice-weekly, depending on the test used and the presence of certain high-risk conditions) is considered medically necessary until delivery. Repeat testing is also considered medically necessary for any significant deterioration in the maternal medical status or any acute diminution in fetal activity, regardless of the amount of time that has elapsed since the last test.
A CST or full BPP is considered medically necessary following an abnormal NST or modified BPP. (Subsequent management should then be predicated on the results of the CST or BPP, the gestational age, the degree of oligohydramnios (if assessed), and the maternal condition.)
Recent, normal antepartum fetal test results should not preclude the determination that intrapartum fetal monitoring is medically necessary.
Umbilical artery Doppler velocimetry is considered medically necessary only in pregnancies complicated by intra-uterine growth restriction, oligohydramnios, twin-twin transfusion syndrome and/or discordant fetuses. Discordant fetal growth is common in multiple gestation and usually is defined by a 15 to 25 % reduction in the estimated fetal weight of the smaller fetus when compared with the largest. (If used in this setting, accepted guidelines indicate that decisions regarding timing of delivery should be made using a combination of information from the Doppler ultrasonography and other tests of fetal well being, along with careful monitoring of maternal status.)
Middle cerebral artery Doppler velocimetry is considered medically necessary for pregnancy complicated by either twin-twin transfusion syndrome or suspected fetal anemia in conditions such as isoimmunization and parvovirus B-19 infection.
Aetna considers uterine artery Doppler studies experimental and investigational for risk assessment or screening during pregnancies because of insufficient evidence.
Aetna considers antepartum fetal surveillance with NST, CST, BPP, modified BPP, and umbilical artery Doppler velocimetry experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above has not been established.
Aetna considers Doppler studies of ductus venosus and vessels other than the middle cerebral artery and umbilical artery for fetal surveillance of impaired fetal growth experimental and investigational because their effectiveness for these indications has not been established.
Antepartum fetal surveillance is used to assess the risk of adverse perinatal outcome associated with utero-placental insufficiency, and is recommended for pregnancies that are at risk for hypoxia and stillbirth. Common tests include fetal movement assessment, non-stress tests (NST), contraction stress tests (CST), biophysical profile (BPP), modified BPP, and umbilical artery Doppler velocimetry. Some of the conditions under which antepartum fetal surveillance may be appropriate include the following:
Maternal conditions:
Anti-phospholipid syndrome
Chronic renal disease
Cyanotic heart disease
Hemoglobinopathies (hemoglobin SS, SC, or S-thalassemia)
Post-term pregnancy (greater than 41 weeks gestation)
Pregnancy-induced hypertension
Previous fetal demise (unexplained or recurrent risk)
Fetal Movement Assessment
A decrease in the maternal perception of fetal movement often but not invariably precedes fetal death, in some cases by several days. This observation provides the rationale for fetal movement assessment by the mother ("kick counts") as a means of antepartum fetal surveillance.
In a review on fetal movement assessment, Froen and colleagues (2008) noted that while almost all pregnant women adhere to it, organized screening by fetal movements has seen variable popularity among health professionals. Early results of screening were promising and fetal movement counting is the only antepartum testing method that has shown effect in reducing mortality in a randomized controlled trial comparing testing versus no testing. Although awareness of fetal movements is associated with improved perinatal outcomes, the quest to define a quantitative "alarm limit" to define decreased fetal movements has so far been unsuccessful, and the use of most such limits developed for fetal movement counting should be discouraged.
Non-Stress Test
The NST is based on the premise that the heart rate of a fetus that is not acidotic or neurologically depressed will temporarily accelerate with fetal movement. Heart rate reactivity is thought to be a good indicator of normal fetal autonomic function. Loss of reactivity is associated most commonly with the fetal sleep cycle but may result from any cause of central nervous system depression, including fetal acidosis and some medications.
To perform NST, the mother is asked to denote when the fetus moves. The fetal heart rate tracing is then evaluated for accelerations of the fetal heart rate corresponding with fetal movement. Alternatively, acoustic stimulation is applied to the maternal abdomen for 1 to 2 seconds and the fetal heart rate is recorded. The acoustic stimulation may be repeated up to 3 times, each time for progressively longer durations (up to 3 seconds), to elicit fetal heart rate accelerations.
Contraction Stress Test
The CST measures the response of the fetal heart rate to uterine contractions. It relies on the premise that fetal oxygenation will be transiently worsened by uterine contractions. This test is rarely used in clinical practice at this time.
To perform CST, the fetal heart rate and uterine contractions are simultaneously recorded with an external fetal monitor. The test lasts until the mother has had 3 moderate strength contractions within a 10-min period. If contractions are not happening on their own, they may be induced using an intravenous dose of oxytocin
Biophysical Profile
BPP is comprised of 5 components:
Amniotic fluid index (determination of the amniotic fluid volume)
Fetal breathing movements
Fetal movement
Fetal tone
Non-stress test
Each component is assigned 2 points, resulting in a score ranging from 0 to 10, with scores from 8 to 10 considered normal, 6 considered borderline, and below 6 considered problematic.
A Cochrane review on BPP for fetal assessment in high-risk pregnancies (Lalor et al, 2008) concluded that there is currently insufficient evidence from randomized trials to support the use of BPP as a test of fetal wellbeing in high-risk pregnancies.
Modified Biophysical Profile
Modified BPP combines the NST (with the option of acoustic stimulation), as a short-term indicator of fetal acid-base status, with the amniotic fluid index as an indicator of long-term placental function.
Umbilical Artery Doppler Velocimetry
A variety of fetal and maternal blood vessels have been evaluated by Doppler wave form analysis to assess the risk of adverse perinatal outcome. The most commonly interrogated vessels are the umbilical arteries.
Umbilical artery Doppler flow velocimetry has been adapted for use as a technique of fetal surveillance, based on the observation that flow velocity waveforms in the umbilical artery of normally growing fetuses differ from those of growth-restricted fetuses. Abnormal flow velocity waveforms have been correlated histopathologically with small-artery obliteration in placental tertiary villi and functionally with fetal hypoxia and acidosis, as well as with perinatal morbidity and mortality.
At least 3 randomized clinical trials (RCTs) have evaluated the utility of umbilical artery Doppler velocimetry as a technique of antepartum fetal surveillance in pregnancies complicated by suspected intrauterine growth restriction. Women assigned to antepartum umbilical artery Doppler velocimetry have been shown to require less frequent antenatal monitoring and shorter durations of maternal hospitalization. The results of 1 RCT showed significantly lower rates of obstetric interventions in patients assigned to Doppler, such as antepartum admission and labor induction. Umbilical artery Doppler velocimetry has not been shown to impact other perinatal outcomes, such as gestational age at birth, birth-weight, Apgar scores, and cesarean birth rates.
Guidelines from the American College of Obstetricians and Gynecologists (ACOG, 1999) have concluded that, "[o]n balance, the available evidence suggests that primary antepartum surveillance of suspected intrauterine growth restriction with umbilical artery Doppler velocimetry can achieve at least equivalent (and possibly better) fetal and neonatal outcomes as primary antepartum surveillance based on results of the NST [non-stress test]. Furthermore, frequency of antepartum testing and certain aspects of obstetric intervention are reduced with use of Doppler." ACOG guidelines (1999) state that, "[i]f umbilical artery Doppler velocimetry is used, decisions regarding timing of delivery should be made using a combination of information from the Doppler ultrasonography and other tests of fetal well-being, such as amniotic fluid volume assessment, NST, CST [contraction stress test], and BPP [biophysical profile], along with careful monitoring of maternal status."
According to ACOG guidelines, "[n]o benefit has been demonstrated for umbilical artery velocimetry for conditions other than suspected intrauterine growth restriction, such as post term gestation, diabetes mellitus, systemic lupus erythematosus, or anti-phospholipid syndrome. Doppler ultrasonography has not been shown to be of value as a screening test for detecting fetal compromise in the general obstetric population, and its use for this purpose cannot be recommended."
American College of Obstetricians and Gynecologists (2000) guidelines on intra-uterine growth retardation (IUGR) reached the following conclusions about the clinical utility of Doppler ultrasound of the umbilical artery:
"Although Doppler velocimetry of the umbilical arteries is not useful as a screening technique for IUGR, it has been demonstrated to be useful once IUGR has been diagnosed. Not only are Doppler velocimetry findings normal in growth-restricted fetuses with chromosomal or other structural etiologies but Doppler velocimetry has been shown to both reduce interventions and improve fetal outcome in pregnancies at risk for IUGR. Thus, once IUGR is suspected or diagnosed, Doppler velocimetry may be useful as a part of fetal evaluation. Fetuses with normal flow patterns seem less likely to benefit from consideration of early delivery than do their counterparts with abnormal studies."
The American College of Radiology (2001) has concluded that Doppler studies are, in general, not indicated for the initial assessment to determine if there is (probable) intrauterine growth retardation.
"Extensive research on Doppler analysis of uterine, umbilical, and various intrafetal vessels confirms a strong correlation between high resistance arterial wave form patterns (e.g., low, absent, or reversed diastolic flow in the umbilical artery) and subsequent IUGR, hypoxemic fetal morbidity, and mortality. The correlation is greatest in high-risk pregnancies, but insufficiently predictive in general, low-risk populations to be useful as a primary screening test. Some have argued that since Doppler appears to be applicable primarily in a population already defined as high risk, the clinical decisions as to when a fetus is distressed and requires emergent delivery will be made based on the BPP and heart rate monitoring, making the Doppler superfluous. A recently published meta-analysis of 20 controlled trials of Doppler ultrasonography found, however, that there is "compelling evidence" that knowledge of the Doppler findings improved perinatal outcome in high-risk pregnancies, reducing antenatal admissions, inductions of labor, and cesarean sections for fetal distress, and reducing the odds of perinatal death by 38 %."
Goffinet et al (1997) reviewed RCTs of umbilical artery Doppler velocimetry in average-risk pregnancies, and concluded that there is inadequate evidence to support its use in that clinical context:
"There is no evidence that routine umbilical Doppler in a general or low-risk population leads to any improvement in the health of women or their infants. Although other trials would be desirable before asserting a definite lack of benefit (due to the problem of statistical heterogeneity and lack of power), umbilical Doppler examination cannot be recommended as a routine test in low- risk pregnancies."
In a Cochrane review, Alfirevic and colleagues (2010) evaluated the effects on obstetric practice and pregnancy outcome of routine fetal and umbilical Doppler ultrasound in unselected and low-risk pregnancies. These investigators searched the Cochrane Pregnancy and Childbirth Group Trials Register (May 2010). Randomized and quasi-RCTs of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms in unselected pregnancies compared to no Doppler ultrasound were selected. Studies where uterine vessels have been assessed together with fetal and umbilical vessels have been included. Two authors independently assessed the studies for inclusion, assessed risk of bias, as well as carried out data extraction. These researchers included 5 trials involving 14,185 women. The methodological quality of the trials was generally unclear because of insufficient data included in the reports. Routine fetal and umbilical Doppler ultrasound examination in low-risk or unselected populations did not result in increased antenatal, obstetric and neonatal interventions, and no overall differences were detected for substantive short-term clinical outcomes such as perinatal mortality. There is no available evidence to assess the effect on substantive long-term outcomes such as childhood neurodevelopment and no data to assess maternal outcomes, particularly psychological effects. The authors concluded that existing evidence does not provide conclusive evidence that the use of routine umbilical artery Doppler ultrasound, or combination of umbilical and uterine artery Doppler ultrasound in low-risk or unselected populations benefits either mother or baby. They stated that future studies should be designed to address small changes in perinatal outcome, and should focus on potentially preventable deaths.
Amniocentesis for amniotic fluid bilirubin levels is the most widely used test to predict the severity of fetal disease in red-cell alloimmunization. Many textbooks and guidelines recommend serial amniocentesis to monitor these pregnancies. However, the reliability of amniotic fluid bilirubin measurements has been questioned and these tests are of limited value in the second trimester. Furthermore, critical appraisal of the very few prospective studies is hampered by limitations in design or insufficient data given by the authors. Two strategies have been proposed by investigators as useful indicators of fetal anemia. Some advocate liberal or primary use of fetal blood sampling, while others promote the use of non-invasive ultrasonography and Doppler assessment of umbilical venous and middle cerebral artery peak systolic velocity (MCA PSV).
The most promising of these methods appears to be MCA PSV. Studies have shown a very good correlation between MCA PSV and the degree of fetal anemia in red blood cell alloimmunized pregnancies known to cause immunological hydrops, that is, a low fetal hematocrit is associated with an increase in MCA PSV and the need to perform a transfusion. This screening method has been shown to have an overall sensitivity of 93 % to detect severe anemia, and a sensitivity of 88 % for moderate anemia. Specificity has been reported to be about 75 %. The false positive rate has been shown to increase following 33 weeks gestation. These high sensitivities and acceptable false-positive rates support the potential clinical applicability of the method to reduce the reliance on, and even replace, cordocentesis and amniocentesis with its attendant complications in Rh maternal alloimmunization pregnancies.
Uterine Artery Doppler
Abnormal uterine artery Doppler studies in the first and second trimester have been associated with subsequent adverse pregnancy outcomes including preeclampsia, fetal growth restriction, and perinatal mortality. However, there is insufficient evidence in the peer-reviewed published medical literature and from evidence-based clinical guidelines for the use of uterine artery Doppler in assessment of either average-risk or high-risk pregnancies. A Cochrane systematic evidence review (Neilson et al, 2003) of Doppler ultrasound for fetal assessment of high-risk pregnancies found that most randomized trials have examined ultrasound of the umbilical artery, not the uterine artery. Only 1 randomized study examined the clinical impact of uterine artery blood flow; in that study, both uterine artery and umbilical artery blood flow were measured. Based on the lack of evidence on the clinical utility of uterine artery blood flow measurements, the Cochrane reviewers concluded: "It is not clear if the study of utero-placental arteries makes any real contribution or not. Fetal vessels other than the umbilical artery can also be studied, especially using pulsed wave Doppler with or without color flow imaging; as yet, there is no evidence from controlled studies that these studies are of clinical value."
Guidelines from the ACOG have concluded that uterine artery Doppler is not an effective method for identifying women at risk for eclampsia. The ACOG guidelines on eclampsia and preeclampsia (2002) state that "Doppler velocimetry of the uterine arteries was reported not to be a useful test for screening pregnant women at low risk for preeclampsia." The ACOG guidelines on intrauterine growth restriction (2000) state that umbilical artery ultrasounds may be useful in the evaluation of the growth restricted fetus; however, these guidelines indicate no particular role for uterine artery Doppler ultrasound in the evaluation and management of intrauterine growth restriction pregnancies.
A review of the evidence for uterine artery Doppler studies prepared for the Society for Maternal Fetal Medicine (Scicione and Hayes, 2009) found that the predictive value of Doppler testing in a low-risk population of women appears to be low, and currently there are no available interventions to prevent adverse outcomes based on an abnormal result. The review found that effective interventions to prevent late pregnancy complications (e.g., preeclampsia, growth restrictions, and perinatal mortality) in women considered at low-risk with abnormal early pregnancy uterine artery Doppler studies are needed. The review concluded that, "[u]ntil such time as these are available, routine uterine artery Doppler screening of women considered at low risk is not recommended."
The review found that uterine artery Doppler screening of high-risk women (e.g., history of chronic hypertension or preeclampsia, prior fetal growth restriction, or stillbirth) with singleton gestations appears to identify those at substantially increased risk for adverse pregnancy outcomes (Scicione and Hayes, 2009). The review stated that abnormal testing in these women could potentially lead to increased surveillance (e.g., earlier and more frequent assessment of fetal growth and maternal clinical condition) and interventions that might improve clinical outcomes. Normal Doppler studies could potentially lead to a reduction in such testing and interventions. The review noted, however, that further study is needed to determine which high-risk conditions are amenable to such screening, what testing regimen is optimal for a normal or abnormal test in these women, and what interventions based on these findings will improve pregnancy outcomes.
The review concluded: "At this time, the evidence does not support routine screening with uterine artery Doppler in any particular group of patients. Use of umbilical artery Doppler should be individualized, and a plan of management based on the results should be put in place. Because standards for the study technique, gestational age, and criteria for an abnormal test are lacking, uterine artery Doppler studies should not be considered to be a required medical practice in low or high risk populations."
Pedrosa and Matias A (2011) performed a systematic review of screening for pre-eclampsia (PE) with the combination of uterine artery Doppler (UAD), maternal history, mean arterial pressure and/or maternal serum markers. These researchers identified eligible studies through Medline searches, and, for each included study, they assessed the risk of bias and extracted relevant data. They reported the performance of screening tests according to the target population (low- or high-risk), the trimester of screening (first and/or second) and the subset of PE screened for (early and late). Several tests provided moderate or convincing prediction of early PE, but screening for late PE was poor. Although UAD is more accurate in the second trimester, these investigators found encouraging results for first-trimester screening when it was combined with other markers. Performance of screening was consistently lower in populations with risk factors for PE in the maternal history. The authors presented encouraging results for the prediction of early PE, even in the first trimester of pregnancy. The different performance of tests in screening for early versus late PE, and of low- versus high-risk populations, supports the concept that PE is a heterogeneous disease.
In a systematic review, Kuc et al (2011) examined the literature on the predictive potential of first-trimester serum markers and of UAD velocity waveform assessment (Ut-A Doppler). Literature on the 7 most studied serum markers (ADAM12, fβ-hCG, Inhibin A, Activin A, PP13, PlGF, and PAPP-A) and Ut-A Doppler was primarily selected. In the selected literature, a combination of these markers was analyzed, and where relevant, the value of maternal characteristics was added. Measurements of serum markers and Ut-A Doppler were performed between week 8 + 0 and 14 + 0 gestational age (GA). Low levels of PP13, PlGF, and PAPP-A and elevated level of Inhibin A have been found to be significantly associated with the development of PE later in pregnancy. The detection rates of single markers, fixed at 10 % false-positive rate, in the prediction of early-onset PE were relatively low, and ranged from 22 % to 83 %. Detection rates for combinations of multiple markers varied between 38 % and 100 %. Therefore, a combination of multiple markers yields high detection rates and is promising to identify patients at high-risk of developing PE. However, the authors stated that large scale prospective studies are needed to evaluate the power of this integrated approach in clinical practice.
In a prospective cohort study, Bezircioglu et al (2012) examined the diagnostic value of blood flow measurements in endometrial, myometrial and uterine vasculature by trans-vaginal Doppler ultrasonography in the differentiation of the neoplastic endometrial pathologies in women with post-menopausal bleeding. A total of 106 women who presented with post-menopausal bleeding were enrolled in this study. Endometrial thickness, pulsatility and resistance indices (PI and RI) of the uterine, myometrial and endometrial vasculature, endometrial histopathology were measured by trans-vaginal Doppler sonography. Dilatation and curettage were performed for all women. Sonographic and histopathological results were evaluated. Endometrial malignancy was diagnosed in 24 of the patients (22.7 %). Endometrial thickness was found to be higher in the patients with malign histopathology compared with the patients of benign histopathology. Statistically, uterine artery PI, RI, radial artery PI, spiral artery PI, and RI were also significantly lower in patients with malign histopathology. According to ROC curve analysis the endometrial thickness of 5 mm, uterine artery PI of 1.450, uterine artery RI of 0.715, radial artery PI of 1.060, and radial artery RI of 0.645 were defined as the cut-off points. In multi-variate regression model, only uterine artery PI was identified as independent determinant of malignant endometrium. The authors concluded that blood flow of uterine artery and also myometrial and endometrial vasculature displayed lower impedance in patients with malignant endometrium, but these lower indices are not already adequate for using as diagnostic tests.
The Society for Maternal-Fetal Medicine Publications Committee’s report on “Doppler assessment of the fetus with intrauterine growth restriction” (Berkley et al, 2012) provided evidence-based guidelines for utilization of Doppler studies for fetuses with IUGR. Relevant documents were identified using PubMed (US National Library of Medicine, 1983 through 2011) publications, written in English, which describe the peri-partum outcomes of IUGR according to Doppler assessment of umbilical arterial, middle cerebral artery, and ductus venosus. Additionally, the Cochrane Library, organizational guidelines, and studies identified through review of the above were utilized to identify relevant articles. Consistent with US Preventive Task Force suggestions, references were evaluated for quality based on the highest level of evidence, and recommendations were graded. Summary of randomized and quasi-randomized studies indicated that, among high-risk pregnancies with suspected IUGR, the use of umbilical arterial Doppler assessment significantly decreases the likelihood of labor induction, cesarean delivery, and perinatal deaths (1.2 % versus 1.7 %; relative risk, 0.71; 95 % confidence interval: 0.52 to 0.98). Antepartum surveillance with Doppler of the umbilical artery should be started when the fetus is viable and IUGR is suspected. Although Doppler studies of the ductus venous, middle cerebral artery, and other vessels have some prognostic value for IUGR fetuses, currently there is a lack of randomized trials showing benefit. Thus, Doppler studies of vessels other than the umbilical artery, as part of assessment of fetal well-being in pregnancies complicated by IUGR, should be reserved for research protocols.
CPT codes not covered for indications listed in the CPB:
93975
93976
ICD-9 codes not covered for indications listed in the CPB:
630 - 679.14
Complications of pregnancy, childbirth, and the puerperium
796.5
Abnormal findings on antenatal screening
V91.00 - V91.99
Multiple gestation placenta status
V22.0 - V28.9
Normal pregnancy, supervision of high-risk pregnancy, postpartum care and examination, encounter for contraceptive management, procreative management, outcome of delivery, and encounter for antenatal screening of mother
Middle cerebral artery Doppler velocimetry:
CPT codes covered if selection criteria are met:
76821
ICD-9 codes covered if selection criteria are met (not all-inclusive):
647.63
Other viral diseases, complicating pregnancy, childbirth, and the puerperium, antepartum condition or complication [parvovirus B-19 infection]
655.30 - 655.31
Suspected damage to fetus from viral disease in mother, affecting management of mother
655.33
Suspected damage to fetus from viral disease in mother, affecting management of mother, antepartum condition or complication
656.03
Fetal-maternal hemorrhage affecting management of mother, antepartum condition or complication
656.13
Rhesus isoimmunization affecting management of mother, antepartum condition or complication
656.23
Isoimmunization from other and unspecified blood-group incompatibility affecting management of mother, antepartum condition or complication
656.53
Poor fetal growth affecting management of mother , antepartum condition or complication
678.03
Fetal hematologic conditions, antepartum condition or complication
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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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