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Clinical Policy Bulletin:
Transabdominal Cerclage
Number: 0529


Policy

Aetna considers transabdominal cerclage medically necessary for the treatment of an incompetent cervix during pregnancy for any of the following conditions:

  1. Previous failed cervical (transvaginal) cerclages; or
  2. Shortened (less than 2.5 cm) or amputated cervix; or
  3. Deep traumatized cervix.

Aetna considers transabdominal cerclage experimental and investigational for all other indications.

Note: A history consistent with incompetent cervix must be documented to establish the medical necessity of this procedure. This includes a history of mid-trimester pregnancy loss that is associated with painless cervical dilatation without evidence of uterine activity.



Background

Incompetent cervix is a significant cause of second-trimester pregnancy loss.  It is portrayed by gradual, painless dilation of the cervix with bulging and rupture of the membranes and subsequent expulsion of a fetus too immature to survive.

The role of cervical cerclage in the prevention of miscarriage due to cervical incompetence is well established yet remains controversial.  The most commonly employed techniques are performed vaginally and are designed to reinforce the cervix at the level of the internal os.  If there is insufficient cervical tissue to allow placement of a cerclage vaginally, a transabdominal approach is sometimes used.  With this procedure, an encircling suture is placed above the cardinal and uterosacral ligaments.  Transabdominal cerclage is not frequently performed and is only indicated for those patients with previous failed cervical cerclages, shortened or amputated cervix, and/or deep traumatized cervix.  This procedure should only be performed by physicians with special training and expertise in this procedure.
 
CPT Codes/ HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
59325
ICD-9 codes covered if selection criteria are met:
654.53 Cervical incompetence complicating pregnancy
654.63 Other congenital or acquired abnormality of cervix complicating pregnancy [shortened, amputated, or deep traumatized cervix]


The above policy is based on the following references:
  1. Cunningham FG, MacDonald PC, Gant NF, et al., eds. Williams Obstetrics. 19th ed. Norwalk, CT: Appleton & Lange; 1993:673-675.
  2. Scott JR, Di Saia, Hammond CB, et al., eds. Danforth's Obstetrics and Gynecology. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999.
  3. Branch DW. Operations for cervical incompetence. Clin Obstet Gynecol. 1986;29(2):240-254.
  4. MacNaughton MC, Chalmers IG, Dubowitz V, et al. Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists multicentered randomized trial of cervical cerclage. Br J Obstet Gynaecol. 1993;100(6):516-523.
  5. Novy MJ. Transabdominal cervicoisthmic cerclage: A reappraisal 25 years after its introduction. Am J Obstet Gynecol. 1991:164(6 Pt 1):1635-1642.
  6. Herron MA, Parer JT. Transabdominal cerclage for fetal wastage due to cervical incompetence. Obstet Gynecol. 1988;71(6 Pt 1):865-868.
  7. Cammarano CL, Herron MA, Parer JT. Validity of indications for transabdominal cervicoisthmic cerclage for cervical incompetence. Am J Obstet Gynecol. 1995:172(6):1871-1875.
  8. Gibb DM, Salaria DA. Transabdominal cervicoisthmic cerclage in the management of recurrent second trimester miscarriage and preterm delivery. Br J Obstet Gynaecol. 1995;102(10):802-806.
  9. Brodman ML, Friedman F Jr, Morrow JD, et al. Wide-band transabdominal cerclage for a foreshortened, incompetent cervix. Obstet Gynecol. 1994;84(4 Pt 2):704-706.
  10. Anthony GS, Walker RG, Cameron AD, et al. Transabdominal cervico-isthmis cerclage in the management of cervical incompetence. Eur J Obstet Gynecol Reprod Biol. 1997;72(2):127-130.
  11. Zaveri V, Aghajafari F, Amankwah K, et al. Abdominal versus vaginal cerclage after a failed transvaginal cerclage: A systematic review. Am J Obstet Gynecol. 2002;187(4):868-872.
  12. Rand L, Norwitz ER. Current controversies in cervical cerclage. Semin Perinatol. 2003;27(1):73-85.
  13. Cho CH, Kim TH, Kwon SH, et al. Laparoscopic transabdominal cervicoisthmic cerclage during pregnancy. Am Assoc Gynecol Laparosc. 2003;10(3):363-366.
  14. Bachmann LM, Coomarasamy A, Honest H, Khan KS. Elective cervical cerclage for prevention of preterm birth: A systematic review. Acta Obstet Gynecol Scand. 2003;82(5):398-404.
  15. Odibo AO, Elkousy M, Ural SH, Macones GA. Prevention of preterm birth by cervical cerclage compared with expectant management: A systematic review. Obstet Gynecol Surv. 2003;58(2):130-136.
  16. Belej-Rak T, Okun N, Windrim R, et al. Effectiveness of cervical cerclage for a sonographically shortened cervix: A systematic review and meta-analysis. Am J Obstet Gynecol. 2003;189(6):1679-1687.
  17. Drakeley AJ, Roberts D, Alfirevic Z. Cervical stitch (cerclage) for preventing pregnancy loss in women. Cochrane Database Syst Rev. 2003;(1):CD003253.
  18. Groom KM, Jones BA, Edmonds DK, Bennett PR. Preconception transabdominal cervicoisthmic cerclage. Am J Obstet Gynecol. 2004;191(1):230-234.
  19. Besio M, Oyarzun E. Transabdominal cervicoisthmic cerclage. Int J Gynaecol Obstet. 2005;88(3):318-320.
  20. American College of Obstericians and Gynecologists. ACOG Practice Bulletin. Cervical insufficiency. Obstet Gynecol. 2003;102(5 Pt 1):1091-1019.
  21. Lotgering FK, Gaugler-Senden IP, Lotgering SF, Wallenburg HC. Outcome after transabdominal cervicoisthmic cerclage. Obstet Gynecol. 2006;107(4):779-784.
  22. Fick AL, Caughey AB, Parer JT. Transabdominal cerclage: Can we predict who fails? J Matern Fetal Neonatal Med. 2007;20(1):63-67.
  23. Oppenheimer L; Society of Obstetricians and Gynaecologists of Canada. Diagnosis and management of placenta previa. J Obstet Gynaecol Can. 2007;29(3):261-273.
  24. Debbs RH, DeLa Vega GA, Pearson S, et al. Transabdominal cerclage after comprehensive evaluation of women with previous unsuccessful transvaginal cerclage. Am J Obstet Gynecol. 2007;197(3):317.e1-e4.


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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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