TRICARE Manuals - Display Chap 4 Sect 18.5 (Baseline, Dec 5, 2022)

Surgery

Chapter 4

Section 18.5

Fetal Surgery

Issue Date: April 17, 2003

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

Revision:

1.0 HCPCS 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 The contractor shall cover fetal surgery for the following indications when provided by a perinatal or pediatric specialist:

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 (MMC).

3.1.5.1 Open fetal surgery for MMC is covered when the gestational age of the fetus is 19.0 to 25.9 weeks and MMC is present with an upper boundary located between T1 through S1 with evidence of hindbrain herniation.

3.1.5.2 The conditions under which prenatal surgery for MMC are performed continue to evolve. If the American College of Obstetricians and Gynecologists (ACOG) publishes expanded recommendations regarding coverage criteria or surgical approach beyond those derived from the Management of MMC Study (MOMS) trial (must not be limited to an institutional review board setting), the contractor shall use those criteria in determining patient eligibility for coverage in accordance with paragraph 3.2.

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, the contractor shall determine coverage for prenatal surgical intervention of temporary tracheal occlusion of Congenital Diaphragmatic Hernia (CDH) for fetuses with a prenatal diagnosis of CDH (Current Procedural Terminology (CPT) code S2400), 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.

Note: The contractor shall not separately reimburse non-directive counseling prior to any fetal surgery or procedure. It is an expected component of good clinical practice and is integrated into the appropriate office visit. The contractor shall cover additional behavioral health care interventions (e.g., psychotherapy, or services of a pastoral counselor), when rendered in accordance with TRICARE policy including Chapter 7, Sections 3.8 and 3.11.

5.0 Contractor Responsibilities

5.1 The contractor shall provide a toll-free number or a call tree option on an existing customer service line for pregnant beneficiaries with a fetal condition or suspected fetal condition and their caregivers or providers can call to request an expedited referral with a perinatal or pediatric specialist.

5.2 Expedited referral. Following the date of receipt of a request for a referral, the contractor shall issue a referral authorization or denial for 100% of all requests within three business days. (See the TRICARE Operations Manual (TOM), Chapter 1, Section 3.)

5.3 The contractor shall monitor and report the performance of the toll-free number or a call tree option on an existing customer service line. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

5.4 The TRICARE Medicare Eligible Program (TMEP) is exempt from the requirements of paragraph 5.0.

5.5 The Designated Provider (DP) contracts and the TRICARE Overseas Program (TOP) are exempt from the requirements of paragraph 5.3.

6.0 EXCLUSIONS

6.1 Fetoscopic surgical repair of MMC.

6.2 Prenatal surgical repair of MMC 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.

6.3 The in-utero repair for aqueductal stenosis (Healthcare Common Procedure Coding System (HCPCS) code S2409) and procedures performed in-utero, not otherwise classified.

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

7.0 Effective Date

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

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