There is absolutely no way I could pay a $12,000 bill. The routine use of pulsed Doppler ultrasound to either document or listen to embryonic/fetal cardiac activity is discouraged. ", "Cell-free fetal DNA-based prenatal testing for fetal sex determination is considered medically necessary for singleton pregnancies at increased risk of a sex (X)-linked condition or congenital adrenal hyperplasia.". Regardless of whether you practice in an office setting or hospital, ACR urges you to oppose a new Anthem Blue Cross Blue Shield outpatient imaging policy which makes imaging a commodity to be performed by the lowest bidder. Anthem Sydney Care is offered through an arrangement with Carelon Digital Platforms, Inc. Sydney Health and Sydney Care are service marks of Carelon Digital Platforms, Inc., 2023. %%EOF
American College of Obstetricians and Gynecologists (ACOG). Sexually Transmitted Infections Treatment Guidelines, 2021. 3Master Precertification List. The sound wave echoes are recorded and displayed as a real-time visual image. 40 Weeks In The Womb by Ultrasound Dimensions Ultrasound Obstet Gynecol. Vox looked into Anthems practice of denying emergency room visits as part of a year-long project on emergency room billing. *Coverage includes fertility preservation services, see Fertility Preservation section. ACOG Practice Bulletin Number 171. endstream
endobj
318 0 obj
<. NCD #220.5. An official website of the State of Georgia. $25copay for primary care Reapproved June 16, 2020. We cannot approve coverage for your emergency room visit.. Updated Discussion and References section. These guidelines impact all our products with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Commonwealth Right now his group is focused on collecting patient stories to get a sense of what the denial policy looks like on the ground. First trimester ultrasound tests alone or in combination with first trimester serum tests for Down's syndrome screening. The document header wording updated from Current Effective Date to Publish Date. Updated Discussion/General Information, References and Websites for Additional Information sections. They got me a wheelchair and wheeled me back to a room immediately, said Cloyd, 27, who lives in Kentucky. MPTAC review. Reaffirmed 2018. 317 0 obj
<>
endobj
When services are Medically Necessary for routine anatomy screen and dating when criteria are met: Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks, 0 days), transabdominal approach; single or first gestation/each additional gestation [includes codes 76801, 76802], Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> 14 weeks 0 days), transabdominal approach; single or first gestation/each additional gestation [includes codes 76805, 76810], Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation/each additional gestation [includes codes 76811, 76812], Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses, Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus, Ultrasound, pregnant uterus, real time with image documentation, transvaginal. Many studies, however, only rely on the final diagnosis. And how many patients are actually being denied? said John Rogers, president-elect of the American College of Emergency Physicians, who practices at a hospital in Macon, Georgia. Washington, DC 20004
Vaccines: Poggenpoel EJ, Geerts LT, Theron GB. Zika virus was first reported in South America in May 2015 and since that time has now appeared in the United States. If you are on a personal connection, like at home, you can run an anti-virus scan on your device to make sure it is not infected with malware. I dont even have $1,000 sitting around.. Were committed to supporting you in providing quality care and services to the members in our network. WebHere you will find information for assessing coverage options, guidelines for clinical utilization management, practice policies, the provider manual and support for delivering They determined that Cloyd had ovarian cysts, not appendicitis. MPTAC review. An abnormal finding on second-trimester ultrasonography that identifies a major congenital anomaly significantly increases the risk of genetic abnormality and warrants further counseling, including the discussion of various prenatal testing strategies. For more information, view our privacy policy. Choose your state below so that we can provide you with the most relevant information. Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first The series has previously explored rising emergency room prices. The policy has so far rolled out in four states: Georgia, Indiana, Missouri, and Kentucky. WebHumana does not cover CPT codes 81420, 81479, or 81507 if used to report any test or any indications other than those listed below in the coverage determination section including, Based on a review by a medical doctor weve evaluated your appeal of denial of ER services, the letter stated. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Anthem reviewed Cloyds appeal two months later and, once again, denied coverage for the visit. Anthem becomes the third national payor to cover the treatment after Aetna and Blue Cross Blue Shield Association gave it positive coverage decisions in April 2021 and August 2018, respectively. endstream
endobj
startxref
Rogers said his group is looking at possible lawsuits or legislation, at either the state or national level. 2 The top tier will cost more in monthly premiums but less in deductibles. Medical Policies & Clinical UM Guidelines, Early and Periodic Screening, Diagnostic and Treatment (EPSDT), HEDIS (The Healthcare Effectiveness Data & Information Set), August 2022 Clinical Utilization Management Guidelines, HEDIS Well Child and Immunizations Coding Bulletin 2023, HEDIS ECDS Prenatal and Postpartum Care Coding Bulletin 2023, Centers of Medical Excellence Transplant Operations Manual, February 2022 Clinical Utilization Management (UM) Guidelines, February 2020 Clinical Utilization Management (UM) Guidelines, May 2020 Clinical Utilization Management (UM) Guidelines, August 2020 Clinical Utilization Management (UM) Guidelines, November 2020 Clinical Utilization Management (UM) Guidelines, May 2021 Clinical Utilization Management (UM) Guidelines, August 2021 Clinical Utilization Management (UM) Guidelines, Provider Experience Quick Reference Guides, HEDIS Prenatal and Postpartum Care ECDS Coding Bulletin 2022, HEDIS Benchmarks and Coding Guidelines for Electronic Clinical Data Systems (ECDS). Anthem has made, and will continue to make, enhancements to our ER program to ensure more effective implementation of this program on behalf of consumers.. Ultrasound examinations can be used to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. 995 0 obj
<>/Filter/FlateDecode/ID[<9E9E9F59C5A2A84EB3B024713636FB8B><40F6644D5DDB024AA2960BB43082D1D5>]/Index[970 57]/Info 969 0 R/Length 118/Prev 418886/Root 971 0 R/Size 1027/Type/XRef/W[1 3 1]>>stream
The uterus, cervix, adnexa, and cul-de-sac region should be examined. Available at: ACOG. The recommendations are based on limited data. Brittany Cloyd was doubled over in pain when she arrived at Frankfort Regional Medical Centers emergency room on July 21, 2017. Anthem Blue Cross and Blue Shield (Anthem) is committed to supporting you in providing quality care and services to the members in our network. Anthems policy appears to be targeted toward pushing patients not to go to the emergency room when they have an injury or illness that could be treated elsewhere. J Pharm Bioallied Sci. Int J Gynaecol Obstet. Emergency room doctors started to notice the change quickly. She didnt get treated at the ER. Previously, CDC recommended serial ultrasounds every 3-4 weeks for women with laboratory evidence of Zika virus infection based on existing fetal growth monitoring for other maternal conditions (e.g., hypertension or diabetes). National Coverage Determination: Ultrasound diagnostic procedures. We use cookies on this website to give you the best experience and measure website usage. We Assess significant discrepancy between uterine size and dates; Follow-up for observation of identified fetal or cord anomaly; Evaluate suspected fetal growth abnormality (either growth restriction or macrosomia), and to follow proven or suspected intrauterine growth restriction; Confirm suspected or follow confirmed diagnosis of polyhydramnios or oligohydramnios; Estimate fetal weight or presentation in premature rupture of membranes or preterm labor; Serial evaluation of fetal growth in multi-fetal pregnancy. 2 These levels allow the member to select the type of deductible, premium, and coverage type they want to have. Webhealth insurance plans covering the same essential health benefits as on-exchange plans are available outside of the exchange or marketplace directly through Anthem. They gave her pain medications that helped her feel better, and an order to follow up with a gynecologist. For more information on your rights to continue coverage contact, the plan at 1-800 -610-1863. She called her mother, a former nurse, who thought it sounded like appendicitis and told Cloyd to go to the hospital immediately. Removed ICD-9 codes from Coding section. An Anthem spokesperson said that the health plan uses both diagnostic codes as well as medical records in their review process. Available at: Centers for Disease Control and Prevention (CDC). A meeting between the health plan and the American College of Emergency Physicians took place in Washington last December but yielded few results. They said they were thinking of looking at medical records, but all of the denials at that point were coming off the claims.. We cannot approve benefits for your recent visit to the emergency room (ER) for pelvic pain, the letter that Cloyd received from Anthem stated, which she shared with Vox. There are no current estimates of how many patients the Anthem policy has affected, or what results it has achieved for the health insurance plan in deterring unnecessary visits. 2021. https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298304d031&searchID=ec8e34c7-2e65-47a7-a410-61774b77a27b&dl=1, American College of Obstetricians and Gynecologists
Ultrasound examinations can be used to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. ET), 2023 Annual Clinical & Scientific Meeting, Congressional Leadership Conference (CLC), Coalition for Access to Prenatal Screening, https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/cell-free-fetal-dna-testing.pdf, https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/mm_0514_coveragepositioncriteria_genetic_testing_repro_carrier_prenatal.pdf, https://www.cigna.com/static/www-cigna-com/docs/individuals-families/master-precertification-list-for-providers.pdf, http://www.aetna.com/cpb/medical/data/400_499/0464.html, https://www.molinahealthcare.com/providers/wa/medicaid/resource/PDF/MCP-157-Noninvasive-Prenatal-Testing.pdf, https://www.mhsindiana.com/content/dam/centene/policies/clinical-policies/CP.MP.84.pdf, https://www.anthem.com/dam/medpolicies/abc/active/guidelines/gl_pw_e000813.html, https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298304d031&searchID=ec8e34c7-2e65-47a7-a410-61774b77a27b&dl=1, Alliance for Innovation on Maternal Health, Postpartum Contraceptive Access Initiative, Maternal age or oocyte age of 35 years or older at delivery; or, Fetal ultrasound findings indicating an increased risk of aneuploidy; or, History of a prior pregnancy with a trisomy; or, Positive first- or second-trimester screening test results for aneuploidy; or, Parental balanced Robertsonian translocation with an increased risk of fetal trisomy 13 or trisomy 21; or, Screening after pre-test counseling from a board-certified genetic counselor or from the prenatal care physician or healthcare professional using Shared Decision-Making (SDM), Laboratory is a qualified Molina par provider; and, Single gestation pregnancy after 10 weeks gestation; and, Pretest and post-test genetic counseling is performed; and, ANY the following indications are present: [ONE], maternal age 35 years or older at delivery, fetal ultrasonographic findings indicating an increased risk of aneuploidy, history of a prior pregnancy with a trisomy, positive first or second-trimester standard biomarker screening test, either parent has been identified as having a balanced Robertsonian translocation with an increased risk of fetal trisomy 13 or trisomy 21.
The sound wave echoes are recorded and displayed as a real-time visual image. 
40 Weeks In The Womb by Ultrasound Dimensions Ultrasound Obstet Gynecol. Vox looked into Anthems practice of denying emergency room visits as part of a year-long project on emergency room billing. *Coverage includes fertility preservation services, see Fertility Preservation section. ACOG Practice Bulletin Number 171. endstream
endobj
318 0 obj
<. NCD #220.5. An official website of the State of Georgia. $25copay for primary care Reapproved June 16, 2020. We cannot approve coverage for your emergency room visit.. Updated Discussion and References section. These guidelines impact all our products with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Commonwealth Right now his group is focused on collecting patient stories to get a sense of what the denial policy looks like on the ground. First trimester ultrasound tests alone or in combination with first trimester serum tests for Down's syndrome screening. The document header wording updated from Current Effective Date to Publish Date. Updated Discussion/General Information, References and Websites for Additional Information sections. They got me a wheelchair and wheeled me back to a room immediately, said Cloyd, 27, who lives in Kentucky. MPTAC review. Reaffirmed 2018. 317 0 obj
<>
endobj
When services are Medically Necessary for routine anatomy screen and dating when criteria are met: Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks, 0 days), transabdominal approach; single or first gestation/each additional gestation [includes codes 76801, 76802], Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> 14 weeks 0 days), transabdominal approach; single or first gestation/each additional gestation [includes codes 76805, 76810], Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation/each additional gestation [includes codes 76811, 76812], Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses, Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus, Ultrasound, pregnant uterus, real time with image documentation, transvaginal. Many studies, however, only rely on the final diagnosis. And how many patients are actually being denied? said John Rogers, president-elect of the American College of Emergency Physicians, who practices at a hospital in Macon, Georgia. Washington, DC 20004
Vaccines: Poggenpoel EJ, Geerts LT, Theron GB. Zika virus was first reported in South America in May 2015 and since that time has now appeared in the United States. If you are on a personal connection, like at home, you can run an anti-virus scan on your device to make sure it is not infected with malware. I dont even have $1,000 sitting around.. Were committed to supporting you in providing quality care and services to the members in our network. WebHere you will find information for assessing coverage options, guidelines for clinical utilization management, practice policies, the provider manual and support for delivering They determined that Cloyd had ovarian cysts, not appendicitis. MPTAC review. An abnormal finding on second-trimester ultrasonography that identifies a major congenital anomaly significantly increases the risk of genetic abnormality and warrants further counseling, including the discussion of various prenatal testing strategies. For more information, view our privacy policy. Choose your state below so that we can provide you with the most relevant information. Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first The series has previously explored rising emergency room prices. The policy has so far rolled out in four states: Georgia, Indiana, Missouri, and Kentucky. WebHumana does not cover CPT codes 81420, 81479, or 81507 if used to report any test or any indications other than those listed below in the coverage determination section including, Based on a review by a medical doctor weve evaluated your appeal of denial of ER services, the letter stated. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Anthem reviewed Cloyds appeal two months later and, once again, denied coverage for the visit. Anthem becomes the third national payor to cover the treatment after Aetna and Blue Cross Blue Shield Association gave it positive coverage decisions in April 2021 and August 2018, respectively. endstream
endobj
startxref
Rogers said his group is looking at possible lawsuits or legislation, at either the state or national level. 2 The top tier will cost more in monthly premiums but less in deductibles. Medical Policies & Clinical UM Guidelines, Early and Periodic Screening, Diagnostic and Treatment (EPSDT), HEDIS (The Healthcare Effectiveness Data & Information Set), August 2022 Clinical Utilization Management Guidelines, HEDIS Well Child and Immunizations Coding Bulletin 2023, HEDIS ECDS Prenatal and Postpartum Care Coding Bulletin 2023, Centers of Medical Excellence Transplant Operations Manual, February 2022 Clinical Utilization Management (UM) Guidelines, February 2020 Clinical Utilization Management (UM) Guidelines, May 2020 Clinical Utilization Management (UM) Guidelines, August 2020 Clinical Utilization Management (UM) Guidelines, November 2020 Clinical Utilization Management (UM) Guidelines, May 2021 Clinical Utilization Management (UM) Guidelines, August 2021 Clinical Utilization Management (UM) Guidelines, Provider Experience Quick Reference Guides, HEDIS Prenatal and Postpartum Care ECDS Coding Bulletin 2022, HEDIS Benchmarks and Coding Guidelines for Electronic Clinical Data Systems (ECDS). Anthem has made, and will continue to make, enhancements to our ER program to ensure more effective implementation of this program on behalf of consumers.. Ultrasound examinations can be used to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. 995 0 obj
<>/Filter/FlateDecode/ID[<9E9E9F59C5A2A84EB3B024713636FB8B><40F6644D5DDB024AA2960BB43082D1D5>]/Index[970 57]/Info 969 0 R/Length 118/Prev 418886/Root 971 0 R/Size 1027/Type/XRef/W[1 3 1]>>stream
The uterus, cervix, adnexa, and cul-de-sac region should be examined. Available at: ACOG. The recommendations are based on limited data. Brittany Cloyd was doubled over in pain when she arrived at Frankfort Regional Medical Centers emergency room on July 21, 2017. Anthem Blue Cross and Blue Shield (Anthem) is committed to supporting you in providing quality care and services to the members in our network. Anthems policy appears to be targeted toward pushing patients not to go to the emergency room when they have an injury or illness that could be treated elsewhere. J Pharm Bioallied Sci. Int J Gynaecol Obstet. Emergency room doctors started to notice the change quickly. She didnt get treated at the ER. Previously, CDC recommended serial ultrasounds every 3-4 weeks for women with laboratory evidence of Zika virus infection based on existing fetal growth monitoring for other maternal conditions (e.g., hypertension or diabetes). National Coverage Determination: Ultrasound diagnostic procedures. We use cookies on this website to give you the best experience and measure website usage. We Assess significant discrepancy between uterine size and dates; Follow-up for observation of identified fetal or cord anomaly; Evaluate suspected fetal growth abnormality (either growth restriction or macrosomia), and to follow proven or suspected intrauterine growth restriction; Confirm suspected or follow confirmed diagnosis of polyhydramnios or oligohydramnios; Estimate fetal weight or presentation in premature rupture of membranes or preterm labor; Serial evaluation of fetal growth in multi-fetal pregnancy. 2 These levels allow the member to select the type of deductible, premium, and coverage type they want to have. Webhealth insurance plans covering the same essential health benefits as on-exchange plans are available outside of the exchange or marketplace directly through Anthem. They gave her pain medications that helped her feel better, and an order to follow up with a gynecologist. For more information on your rights to continue coverage contact, the plan at 1-800 -610-1863. She called her mother, a former nurse, who thought it sounded like appendicitis and told Cloyd to go to the hospital immediately. Removed ICD-9 codes from Coding section. An Anthem spokesperson said that the health plan uses both diagnostic codes as well as medical records in their review process. Available at: Centers for Disease Control and Prevention (CDC). A meeting between the health plan and the American College of Emergency Physicians took place in Washington last December but yielded few results. They said they were thinking of looking at medical records, but all of the denials at that point were coming off the claims.. We cannot approve benefits for your recent visit to the emergency room (ER) for pelvic pain, the letter that Cloyd received from Anthem stated, which she shared with Vox. There are no current estimates of how many patients the Anthem policy has affected, or what results it has achieved for the health insurance plan in deterring unnecessary visits. 2021. https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298304d031&searchID=ec8e34c7-2e65-47a7-a410-61774b77a27b&dl=1, American College of Obstetricians and Gynecologists
Ultrasound examinations can be used to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. ET), 2023 Annual Clinical & Scientific Meeting, Congressional Leadership Conference (CLC), Coalition for Access to Prenatal Screening, https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/cell-free-fetal-dna-testing.pdf, https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/mm_0514_coveragepositioncriteria_genetic_testing_repro_carrier_prenatal.pdf, https://www.cigna.com/static/www-cigna-com/docs/individuals-families/master-precertification-list-for-providers.pdf, http://www.aetna.com/cpb/medical/data/400_499/0464.html, https://www.molinahealthcare.com/providers/wa/medicaid/resource/PDF/MCP-157-Noninvasive-Prenatal-Testing.pdf, https://www.mhsindiana.com/content/dam/centene/policies/clinical-policies/CP.MP.84.pdf, https://www.anthem.com/dam/medpolicies/abc/active/guidelines/gl_pw_e000813.html, https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298304d031&searchID=ec8e34c7-2e65-47a7-a410-61774b77a27b&dl=1, Alliance for Innovation on Maternal Health, Postpartum Contraceptive Access Initiative, Maternal age or oocyte age of 35 years or older at delivery; or, Fetal ultrasound findings indicating an increased risk of aneuploidy; or, History of a prior pregnancy with a trisomy; or, Positive first- or second-trimester screening test results for aneuploidy; or, Parental balanced Robertsonian translocation with an increased risk of fetal trisomy 13 or trisomy 21; or, Screening after pre-test counseling from a board-certified genetic counselor or from the prenatal care physician or healthcare professional using Shared Decision-Making (SDM), Laboratory is a qualified Molina par provider; and, Single gestation pregnancy after 10 weeks gestation; and, Pretest and post-test genetic counseling is performed; and, ANY the following indications are present: [ONE], maternal age 35 years or older at delivery, fetal ultrasonographic findings indicating an increased risk of aneuploidy, history of a prior pregnancy with a trisomy, positive first or second-trimester standard biomarker screening test, either parent has been identified as having a balanced Robertsonian translocation with an increased risk of fetal trisomy 13 or trisomy 21.