2.0 DESCRIPTION
Maternity
care is the medical services related to conception, delivery and
pregnancy loss, including prenatal and postpartum care (generally
through the sixth post-delivery week), and treatment of complications
of pregnancy.
3.0 POLICY
3.1 Services and
supplies associated with antepartum care (including well-being of
the fetus), childbirth, postpartum care, and complications of pregnancy
may be covered.
3.2 The
maternity care benefit includes, but is not limited to, the following
prenatal screening tests:3.2.1 Anemia
Screening:
3.2.2 Asymptomatic
Bacteriuria, Urinary Tract, or Other Infection Screening. Screen
with urine culture for women 12-16 weeks gestation, or at first
prenatal visit, if later.
3.2.3 Gestational
Diabetes Mellitus Screening. Screen women 24-28 weeks pregnant and
those at high risk of developing gestational diabetes.
3.2.4 Hepatitis
B Screening. Screen pregnant women for HBsAG during the prenatal
period.
3.2.5 Human
Immunodeficiency Virus (HIV) Infection Screening.
3.2.6 Rh
Incompatibility Screening. Screen all pregnant women and provide
follow-up testing for pregnant women at high risk.
3.2.7 Syphilis
Infection Screening.
3.2.8 Other
screening tests as recommended by the United States Preventive Services
Task Force.
3.3 Genetic
testing is considered preventive rather than active medical treatment.
However, under the family planning benefit, genetic testing, including
testing done as part of routine prenatal care, is covered when performed
in certain high risk situations. For the purpose of the TRICARE
benefit, genetic testing may include specific tests to detect developmental
abnormalities as well as tests for specific genetic defects.
3.4 The
mother and child hospital Length-of-Stay (LOS) benefit may not be
restricted to less than 48 hours following a normal vaginal delivery
and 96 hours following a cesarean section. The decision to discharge
prior to those minimum LOSs must be made by the attending physician
in consultation with the mother.
3.5 Maternity care for pregnancy resulting
from noncoital reproductive procedures may be cost-shared. Where
the contractual arrangements do not specify an amount for reimbursement
for medical expenses, the full amount of all undesignated payments
shall be deemed to be for medical expenses incurred by the surrogate
mother. TRICARE will cost-share on the remaining balance of otherwise covered
benefits related to the surrogate mother’s medical expenses after
the contractually agreed upon arrangement has been exhausted.
3.6 For
pregnancies in which the TRICARE beneficiary is a surrogate mother,
services and supplies associated with antepartum
care, childbirth, postpartum care, and complications of pregnancy
may be cost-shared.
3.8 Progesterone
therapy for the prevention of preterm birth is covered only for
weekly injections of 17 alpha-hydroxyprogesterone caproate between
16 and 36 weeks of gestation for pregnant women with a documented
history of a previous spontaneous birth at less than 37 weeks of
gestation.
4.0 EXCLUSIONS
4.1 Oral progesterone
therapy or injections of 17 alpha-hydroxyprogesterone caproate are NOT covered
for other high risk factors for preterm birth, including, but not
limited to multiple gestations, short cervical length, or positive
fetal tests for cervicovaginal fetal fibronectin.
4.2 Services and
supplies related to noncoital reproductive procedures.
4.3 Home Uterine
Activity Monitoring (HUAM), telephonic transmission of HUAM data,
or HUAM-related telephonic nurse or physician consultation for the
purpose of monitoring suspected or confirmed pre-term labor is unproven.
4.4 Subcutaneous
terbutaline pump and home use of maintenance subcutaneous terbutaline
to suppress labor is unproven.
4.5 Lymphoctye or paternal leukocyte immunotherapy
in the treatment of recurrent spontaneous fetal loss is unproven.
4.6 Salivary estriol
test for preterm labor is unproven (CPT procedure code 82677).