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.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
MEDICAL APPROPRIATENESS
Fetal echocardiography for the diagnosis and assessment of high-risk congenital heart disease is considered medically appropriate for any of the following fetal and / or maternal risk factors:
Fetal Risk Factors
Extracardiac abnormality
Chromosomal abnormality
Fetal cardiac arrhythmia
Non-immune hydrops
Question of cardiac anomaly on prior sonogram
Intrauterine growth retardation
Maternal Risk Factors
Family history of congenital heart disease (parent or sibling)
Teratogenic exposure (e.g., alcohol, amphetamines, anticonvulsives, lithium)
Maternal disorders (e.g., diabetes mellitus, collagen vascular disease, phenylketonuria)
Maternal infection (e.g., rubella)
Familial syndromes
ADDITIONAL INFORMATION
No controlled studies were found in the published literature that validate the application of fetal echocardiography for the treatment of other conditions / diseases.
Fetal echocardiography for the treatment of other conditions / diseases does not meet the following technology evaluation criteria:
The technology must have final approval from the appropriate government regulatory bodies.
The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
The technology must improve the net health outcome.
The technology must be as beneficial as any established alternatives.
The improvement must be attainable outside the investigational settings.
SOURCES
Ayres, N. A. (1998). Fetal echocardiography: who needs it? Cardiology in Review, 6 (3), 156-167. Abstract retrieved October 30, 2001 from PubMed database.
Bernstein, D. (2004). Laboratory evaluation: Radiologic assessment. In Behrman (Ed.), Nelson Textbook of Pediatrics (17 th ed., p. 1495). Philadelphia: W. B. Saunders Company.
BlueCross BlueShield Association, Medical Policy Reference Manual. (2:2003). Fetal Echocardiography. (4.01.01). Retrieved February 21, 2006 from BlueWeb.
Cheitlin, M. D., Armstrong, W. F., Aurigemma, G. P., Beller, G. A., Bierman, F. Z., Davis, J. L., et al. (2003). ACC/AHA guidelines for the clinical application of echocardiography: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Retrieved February 21, 2006 from http://www.acc.org/clinical/topic/topic.htm#E.
Sklansky, M. S., Nelson, T., Strachan, M., Pretorius, D. (1999). Real-time three-dimensional fetal echocardiography: initial feasibility study. Journal of Ultrasound in Medicine, 18 (11), 745-752.
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EFFECTIVE DATE |
5/25/2006 |
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