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
Fetal cardiac arrhythmia
Non-immune hydrops
Question of cardiac anomaly on prior sonogram
Intrauterine growth retardation
ANY ONE of the following 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
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. (2008, October). Fetal echocardiography. Retrieved January 29, 2009 from http://www.americanheart.org/presenter.jhtml?identifier=3005386.
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2003). Fetal Echocardiography (4.01.01). Retrieved January 29, 2009 from BlueWeb. (0 articles and/or guidelines reviewed)
Cheitlin, M. D., Armstrong, W. F., Aurigemma, G. P., Beller, G. A., Bierman, F. Z., Davis, J. L., et al. (2003). ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to update the 1997 guidelines for the clinical application of echocardiography). Journal of the American College of Cardiology, 42 (5), 954-970.
Di Salvo, G., Russo, M. G., Paladini, D., Felicetti, M., Castaldi, B., Tartaqlione, A., et al. (2008). Two-dimensional strain to assess regional left and right ventricular longitudinal function in 100 normal foetuses. European Journal of Echocardiography, 9 (6), 754-756. (Level 3 Evidence - Independent study)
Goncalves, L. F., Espinoza, J., Romero, R., Lee, W., Treadwell, M. C., Huang, R., et al. (2005). Four-dimensional fetal echocardiography with spatiotemporal image correlation (STIC): A systematic study of standard cardiac views assessed by different observers. The Journal of Maternal-Fetal & Neonatal Medicine, 17 (5), 323-331. (Level 3 Evidence - Independent study)
Hamar, B. D., Dziura, J., Friedman, A., Kleinman, C. S., & Copel, J. A. (2006). Trends in fetal echocardiography and implications for clinical practice: 1985 to 2003. Journal of Ultrasound in Medicine, 25 (2), 197-202. Abstract retrieved February 2, 2009 from PubMed database. (Level 1 Evidence)
Hayes. Medical Technology Directory. (2006, February). Three-dimensional and four-dimensional ultrasound for fetal cardiovascular diagnosis. Retrieved January 29, 2009 from www.Hayesinc.com/subscribers. (28 articles and/or guidelines reviewed)
Quinones, M A., Douglas, P. S., Foster, E., Gorcsan, J., Lewis, J. F., Pearlman, A. S., et al. (2003). American College of Cardiology/American Heart Association Clinical Competence Statement on Echocardiography: A report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on clinical competence. Circulation, 107 (7), 1068-1089.
Smrcek, J. M., Berg, C., Geipel, A., Fimmers, R., Axt-Fliedner, R., Diedrich, K., et al. (2006). Detection rate of early fetal echocardiography and in utero development of congenital heart defects. Journal of Ultrasound in Medicine, 25 (2), 187-196. Abstract retrieved February 2, 2009 from PubMed database.
Tutschek, B., & Sahn, D. J. (2007). Three-dimensional echocardiography for studies of the fetal heart: Present status and future perspectives. Cardiology Clinics, 25 (2), 341-355.
ORIGINAL EFFECTIVE DATE: 11/1987
MOST RECENT REVIEW DATE: 3/12/2009
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.
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