Fetal Surgery for Prenatally Diagnosed Malformations

Section: Maternity
Effective Date: March 02, 2020
Revised Date: January 22, 2020
Last Reviewed: January 22, 2020

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

59076 S2401 S2409

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

59076 59897 S2402 S2403 S2409

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

59897 S2405 S2409

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

S2404 S2409

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

S2400 S2409

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 59076 and S2401

O35.8XX0 O35.8XX1 O35.8XX2 O35.8XX3 O35.8XX4 O35.8XX5 O35.8XX9
O41.00X0 O41.00X1 O41.00X2 O41.00X3 O41.00X4 O41.00X5 O41.00X9
O41.01X0 O41.01X1 O41.01X2 O41.01X3 O41.01X4 O41.01X5 O41.01X9
O41.02X0 O41.02X1 O41.02X2 O41.02X3 O41.02X4 O41.02X5 O41.02X9
O41.03X0 O41.03X1 O41.03X2 O41.03X3 O41.03X4 O41.03X5 041.03X9
Q64.2 Q64.31 Q64.32 Q64.33 Q64.39

 

Covered Diagnosis Codes for procedure codes 59076 and S2402

Q33.0 O35.8XX0 O35.8XX1 O35.8XX2 O35.8XX3 O35.8XX4 O35.8XX5
O35.8XX9

 

Covered Diagnosis Codes for Procedure Codes 59076 and S2403

Q33.2 Q33.3 Q33.6

 

Covered Diagnosis Codes for Procedure Code S2404

O33.7XX0 O33.7XX1 O33.7XX2 O33.7XX3 O33.7XX4 O33.7XX5 O33.7XX9
Q05.0 Q05.1 Q05.2 Q05.3 Q05.4 Q05.5 Q05.6
Q05.7 Q05.9 Q07.00 Q07.01 Q07.02 Q07.03

 

Covered Diagnosis Codes for Procedure Code S2405

O33.7XX0 O33.7XX1 O33.7XX2 O33.7XX3 O33.7XX4 O33.7XX5 O33.7XX9

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