Description

Fetal surgery typically involves opening the gravid uterus (with either a traditional Cesarean surgical incision or through single or multiple fetoscopic port incisions), surgically correcting a fetal abnormality, and returning the fetus to the uterus and restoring uterine closure.

Criteria

Vesico-amniotic shunting as a treatment of urinary tract obstruction may be considered medically necessary in fetuses under the following conditions:

• Evidence of hydronephrosis due to bilateral urinary tract obstruction; and 
• Progressive oligohydramnios; and
• Adequate renal function; and 
• No other lethal abnormalities or chromosomal defects.

Procedure Codes

Open in utero resection of malformed pulmonary tissue or placement of a thoraco-amniotic shunt may be considered medically necessary under the following conditions:

• Congenital cystic adenomatoid malformation (CCAM) or bronchopulmonary sequestration is identified; and 
• The fetus is at 32 weeks gestation or less; and 
• There is evidence of fetal hydrops, placentomegaly, and/or the beginnings of severe pre-eclampsia (i.e., the maternal mirror syndrome) in the mother.

Procedure Codes

In utero removal of sacrococcygeal teratoma (SCT) may be considered medically necessary under the following conditions:

• The fetus is at 32 weeks gestation or less; and 
• There is evidence of fetal hydrops, placentomegaly, and/or the beginnings of severe pre-eclampsia (i.e., maternal mirror syndrome) in the mother.

Procedure Codes

In utero closure of myelomeningocele (MMC) may be considered medically necessary under the following conditions:

• The fetus is at less than 26 weeks gestation; and 
• Myelomeningocele is present with an upper boundary located between T1 and S1 with evidence of hindbrain herniation.

Procedure Codes

Fetal surgery is considered experimental/investigational for all other conditions including but not limited to those indicated below due to insufficient evidence of efficacy.

• Fetal surgery for aqueductal stenosis; or
• Fetal surgery for congenital diaphragmatic hernia using temporary tracheal occlusion.

Procedure Codes

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 59076 and S2401

Covered Diagnosis Codes for procedure codes 59076 and S2402

Covered Diagnosis Codes for Procedure Codes 59076 and S2403

Covered Diagnosis Codes for Procedure Code S2404

Covered Diagnosis Codes for Procedure Code S2405