More than 1 detailed ultrasound fetal anatomic examination per pregnancy per practice is considered experimental and investigational, as there is inadequate evidence of the clinical utility of multiple serial detailed fetal anatomic ultrasound examinations during pregnancy.Īetna considers detailed ultrasound fetal anatomic examination experimental and investigational for all other indications including routine evaluation of pregnant women who are on bupropion (Wellbutrin) or levetiracetam (Keppra), pregnant women with low pregnancy-associated plasma protein A, pregnant women with myasthenia gravis, and pregnant women who smoke or abuse cannabis. Use of detailed fetal US at 20 weeks based on previous pregnancy with a child with DiGeorge syndrome.To diagnose / evaluate uterus didelphys.To evaluate the fetus of a mother who has a bicornuate uterus or uterus didelphys.Previous pregnancy with a fetus that had an ultrasound detectable congenital anomaly associated with an elevated risk of recurrence in the current pregnancy or.Pregnancy in woman with untreated or inadequately treated syphilis or.Known or suspected exposure to Zika virus or.Obesity (prepregnancy body mass index of 30 kg/m 2 or more) complicating pregnancy or.Pregnancies resulting from advanced reproductive technology (ART) Footnote1* or.Anatomic abnormalities due to genetic conditions (see attached ICD-10 coding) or.Abnormal serum markers screening for fetal aneuploidy (triple or quad screening) (see CPB 464 - Serum and Urine Marker Screening for Fetal Aneuploidy) or. If there are known or suspected fetal anatomic abnormalities, including:
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