Treatments of Twin-to-Twin Transfusion Syndrome (TTTS)
DESCRIPTION
Twin-to-twin transfusion syndrome (TTTS) occurs in cases of monozygotic monochorionic (one placenta) twins. In TTTS twins share a single placenta that contains blood vessels that abnormally connect the fetuses to each other. These connections allow blood to pass from one fetus to the other and create an imbalance of blood between the fetuses. As a result, the twin donating the blood can experience growth retardation, anemia, and oligohydramnios (reduced amniotic fluid). The twin receiving the blood can experience polyhydramnios (excessive amniotic fluid) and vascular engorgement, leading to congestive heart failure and hydrops fetalis (excessive accumulation of serous fluid in the tissues and body cavities).
Treatment options for TTTS include serial amnioreduction and fetoscopic laser photocoagulation of the placental vessels that join the fetuses. Serial amnioreduction is a variant of amniocentesis in which amniotic fluid is repeatedly removed in order to restore normal fluid volume. In fetoscopic laser photocoagulation, the abnormal connection of the placental vessels is identified endoscopically under ultrasound guidance and ablated using a laser. This separates the two fetal circulations, correcting the underlying abnormality. The alternative to prenatal intervention is conservative management, which is associated with a fetal mortality rate between 90 percent and 100 percent.
POLICY
Amnioreduction for the treatment of twin-to-twin transfusion syndrome prior to 28 weeks gestation is considered medically necessary.
Laser photocoagulation therapy for the treatment of twin-to-twin transfusion syndrome prior to 28 weeks gestation is considered medically necessary.
Amnioreduction in combination with laser photocoagulation therapy for the treatment of twin-to-twin transfusion syndrome prior to 28 weeks gestation is considered medically necessary.
Policies with similar titles: Fetal Surgery for Prenatally Diagnosed Malformations
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ADDITIONAL INFORMATION
Randomized controlled studies of serial amnioreduction and fetoscopic laser photocoagulation are difficult to undertake because of the limited numbers of candidates available at centers that provide the procedure and because of the ethical issues involved in withholding treatment to candidates in control groups in which perinatal mortality can reach 90 percent. When compared to serial amnioreduction, fetoscopic laser photocoagulation has resulted in fewer reports of neurologic morbidity in surviving children.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2004). Treatment of twin-twin syndrome with amnioreduction and/or fetoscopic laser therapy (4.01.12). Retrieved January 9, 2012 from BlueWeb. (5 articles and/or guidelines reviewed)
Crombleholme, T., Shera, D., Lee, H., Johnson,M., D’Alton,M., Porter, F., et al. ( 2007). A prospective, randomized, multicenter trial of amnioreduction vs selective fetoscopic laser photocoagulation for the treatment of severe twin-twon transfusion syndrome. American Journal of Obstetrics and Gynecology, 197 (4), 396e 1 - 396e9. (Level 2 Evidence).
Habli, M., Lim, F., & Crombleholme, T. (2009). Twin-to-twin transfusion syndrome: a comprehensive update. Clinical perinatol, 36 (2), 391 - 416. (Level 5 Evidence)
ORIGINAL EFFECTIVE DATE: 4/11/2008
MOST RECENT REVIEW DATE: 2/9/2012
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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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