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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 18.2
Antepartum Services
Issue Date:  March 3, 1992
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT PROCEDURE CODES
59000 - 59051, 59070, 59072, 59074, 59076
2.0  DESCRIPTION
Antepartum services include amnoiocentesis, (transabdominal needle aspiration of amniotic fluid), chordocentesis (percutaneous puncture of the umbilical vein to obtain fetal blood sample), chorionic villus sampling (transabdominal or transcervical aspiration of the villus tissue), fetal stress tests, and electronic fetal monitoring. These services are performed to detect genetic abnormalities, hemolytic disease and metabolic disorders, assess fetal age, pulmonary maturity and health, and determine fetal stress.
3.0  POLICY
3.1  Amniocentesis, chordocentesis, and chorionic villus sampling are covered when:
3.1.1  Performed to assess fetal lung maturity for preterm labor or delivery because of life-endangering fetal and/or maternal conditions.
3.1.2  Performed to assess the degree of fetal involvement in hemolytic disease.
3.1.3  Performed for genetic testing when:
3.1.3.1  The mother is 35 years old or older, or will be 35 by delivery; or
3.1.3.2  The mother or father has had a previous child born with a congenital abnormality; or
3.1.3.3  The mother or father has a family history of congenital abnormalities; or
3.1.3.4  The mother contracted rubella during the first trimester of pregnancy; or
3.1.3.5  There is a history of three or more spontaneous abortions in the current marriage or in previous mating of either spouse; or
3.1.3.6  The fetus is at an increased risk for a hereditary error of metabolism detectable in vitro; or
3.1.3.7  The fetus is at an increased risk for neural tube defect (family history or elevated maternal serum alpha-fetoprotein level); or
3.1.3.8  There is a history of sex-linked conditions (i.e., Duchenne muscular dystrophy, hemophilia, x-linked mental retardation, etc.).
3.2  Electronic fetal monitoring, supervision, and interpretation is covered.
4.0  EXCLUSIONS
Antepartum services are excluded when:
4.1  Performed to establish paternity of a child.
4.2  Performed solely to determine the sex of an unborn child for non-medical reasons.
4.3  Genetic testing for a condition in an individual or pregnancy not considered at increased risk.
4.4  Isoimmunization to the ABO blood antigens.
- END -

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