Fetal Echocardiography
DESCRIPTION
Fetal echocardiography is a non-invasive technique for diagnosing and assessing cardiac abnormalities in the fetus. Fetal echocardiography is performed using a two-dimensional (2-D) high-resolution ultrasound system, which usually also has other capabilities including M-mode. Pulsed Doppler and color Doppler mapping are newer developments.
These techniques are used to define the structural and functional aspects of the cardiac abnormality. While 2-D echocardiography can detect structural changes, Doppler echocardiography is used to measure flow velocity, direction of flow, pressure differences, and cardiac output.
Generally, the standard 2-D echocardiogram is performed, and if a structural abnormality is found color Doppler flow mapping may be used to quickly localize the abnormal area of altered flow. Measurements by pulsed wave Doppler may be made to reduce the duration of fetal exposure to high-intensity ultrasound. Pulsed Doppler alone may be used after 2-D echocardiography to complete a diagnosis.
Diagnosis of fetal arrhythmia requires M-mode echocardiography. Pulsed Doppler echocardiography is also used.
POLICY
Fetal echocardiography for the diagnosis and assessment of high-risk congenital heart disease is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Fetal echocardiography for the screening of routine pregnancies is considered not medically necessary.
Fetal echocardiography for the treatment of other conditions/diseases is considered investigational.
MEDICAL APPROPRIATENESS
Fetal echocardiography for the diagnosis and assessment of high-risk congenital heart disease is considered medically appropriate for ANY ONE of the following:
ANY ONE of the following fetal risk factors:
Extracardiac abnormality
Chromosomal abnormality
Cardiac arrhythmia
Hydrops
Question of cardiac anomaly on prior sonogram
Intrauterine growth retardation
Increased nuchal translucency
Monochorionic twins
Unexplained severe polyhydramnios
ANY ONE of the following maternal risk factors:
First degree relative with congenital heart disease (parent or sibling)
Teratogenic exposure (e.g., alcohol, amphetamines, anticonvulsives, lithium)
Metabolic disorders (e.g., diabetes mellitus, phenylketonuria)
Infection (e.g., rubella)
Familial syndromes
Autoimmune disorders or antibodies, anti-Ro (SSA) / anti-La (SSB) or disorders
In vitro fertilization
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
No controlled studies were found in the published literature that validates the application of fetal echocardiography for the treatment of other conditions/diseases.
SOURCES
American Heart Association. (2011). Fetal echocardiography / Your unborn baby’s heart. Retrieved February 9, 2012 from http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/SymptomsDiagnosisofCongenitalHeartDefects/Fetal-Echocardiography-Your-Unborn-Babys-Heart_UCM_315640_Article.jsp.
American Institute of Ultrasound in Medicine (AIUM). (2010). AIUM practice guidelines for the performance of fetal echocardiography. Retrieved February 9, 2012 from https://www.smfm.org/attachedfiles/fetalEchoaiumsmfm.pdf.
American Society of Echocardiography. (2004). American society of echocardiography guidelines and standards for performance of the fetal echocardiogram. Retrieved February 9, 2012 from http://www.ilfeto.it/site/images/stories/linee_guida/guidelines_standards_4_performance.pdf.
BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2011). Fetal Echocardiography. (2.01.82) - Archived. Retrieved February 8, 2012 from BlueWeb. (0 articles and/or guidelines reviewed)
Simpson, J. M. (2009). Impact of fetal echocardiography. Annals of Pediatric Cardiology, 2 (1), 41-50.
ORIGINAL EFFECTIVE DATE: 11/1987
MOST RECENT REVIEW DATE: 4/12/2012
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.