TRICARE Manuals - Display Chap 4 Sect 18.5 (Change 37, Dec 4, 2018)

Chapter 4

Section 18.5

Fetal Surgery

Issue Date: April 17, 2003

Authority: 32 CFR 199.4(c)(2)(i)

Revision:

1.0 HCPCS Procedure Codes

S2401- S2405, S2411

2.0 DEFINITION

Fetal surgery is defined as an intervention consisting of opening of the gravid uterus (by either a traditional cesarean surgical incision or through single or multiple fetoscopic port incisions), surgically correcting a fetal abnormality, and either returning the fetus to the uterus (or restoring uterine closure, if the intervention has been accomplished without removal of the fetus) for completion of gestational development.

3.0 POLICY

3.1 Fetal surgery is covered for the following indications:

3.1.1 Prenatal surgical intervention consisting of vesicoamniotic shunting in fetuses with hydronephrosis due to bilateral urinary tract obstruction together with evidence of progressive oligohydramnios and evidence of adequate renal function as generally defined by normal urinary electrolytes, and with no other lethal abnormalities or chromosomal defects.

3.1.2 Prenatal intervention of either an open in-utero resection of malformed pulmonary tissue or placement of a thoraco-amniotic shunt in cases of hydrothorax or large cystic lesions for fetuses congenital cystic adenomatoid malformation or extralobar pulmonary sequestration, who are of less than 32 weeks’ gestation and who have evidence of progressive hydrops, placentomegaly and/or the beginnings of maternal mirror syndrome.

3.1.3 Twin-twin transfusion syndrome, gestation age of less than 25 weeks’ gestation at the time of diagnosis.

3.1.4 Sacrococcygeal teratoma in the presence of fetal hydrops and/or placentomegaly in fetuses with less than 28 weeks of gestation.

3.1.5 Prenatal surgical repair of myelomeningocele when the gestational age of the fetus is 19.0 to 25.9 weeks and myelomeningocele is present with an upper boundary located between T1 through S1 with evidence of hindbrain herniation.

3.2 Other conditions when determined by medical review to be medically necessary and appropriate treatment for the patient’s medical condition and that reliable evidence has established in-utero surgery as safe and effective treatment.

4.0 Considerations

For dates of services on or after October 1, 2009, coverage for prenatal surgical intervention of temporary tracheal occlusion of Congenital Diaphragmatic Hernia (CDH) for fetuses with a prenatal diagnosis of CDH (CPT procedure code S2400), shall be determined on a case-by-case basis, based on the Rare Disease policy. Procedural guidelines for review of rare disease are contained in Chapter 1, Section 3.1.

5.0 EXCLUSIONS

5.1 The in-utero surgical repair of myelomeningocele in patients who have one or more of the following:

• Fetal anomaly unrelated to myelomeningocele.

• Severe kyphosis.

• Risk of pre-term birth (e.g., short cervix or previous pre-term birth).

• Maternal body mass index of 35 or more.

5.2 The in-utero repair for aqueductal stenosis (HCPCS S2409) and procedures performed in-utero, not otherwise classified.

5.3 In-utero surgery for other conditions for which the safety and effectiveness has not been established.

6.0 Effective Date

Prenatal surgical repair of myelomeningocele is covered, effective February 9, 2011.

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