Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Abortion
Policy #:MA11.010a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Abortions are covered and eligible for reimbursement consideration by the Company when any of following requirements are met:
  • If the pregnancy is the result of an act of rape or incest.
  • In the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a professional provider, place the woman in danger of death unless an abortion is performed.

Abortions performed for any other indication are considered not covered and, therefore, not eligible for reimbursement.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, abortion is covered under the medical benefits of the Company’s Medicare Advantage products when the coverage criteria listed in this medical policy are met.

For Medicare Advantage members, certain drugs are available through either the member's medical benefit (Part B benefit) or pharmacy benefit (Part D benefit), depending on how the drug is prescribed, dispensed, or administered. This medical policy only addresses instances when medical abortion drugs are covered under a member's medical benefit (Part B benefit). It does not address instances when medical abortion drugs are covered under a member’s pharmacy benefit (Part D benefit).

Description

Abortion is defined as the expulsion or extraction of the products of conception from the uterus prior to the state of viability. Abortions are classified as elective or non-elective.
References

Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD). 140.1: Abortion. [CMS Web site]. 06/19/06. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=127&ncdver=2&bc=BAABAAAAAAAA&. Accessed March 19, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Z33.2 Encounter for elective termination of pregnancy



HCPCS Level II Code Number(s)



S0199 Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion) except drugs

S2260 Induced abortion, 17 to 24 weeks

S2265 Induced abortion, 25 to 28 weeks

S2266 Induced abortion, 29 to 31 weeks

S2267 Induced abortion, 32 weeks or greater


THE FOLLOWING CODES ARE USED TO REPRESENT MEDICATIONS ASSOCIATED WITH NON-SURGICAL ABORTIONS:

J8610 Methotrexate; oral, 2.5 mg

J9250 Methotrexate sodium, 5 mg

J9260 Methotrexate sodium, 50 mg

S0190 Mifepristone, oral, 200 mg

S0191 Misoprostol, oral, 200 mcg


Revenue Code Number(s)

N/A


Misc Code

Modifier:

Modifier G7 Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening


Coding and Billing Requirements

The G7 modifier should be reported with the appropriate CPT and/or HCPCS code.






Policy History

Revisions from MA11.010a
04/08/2020This policy has been reissued in accordance with the Company's annual review process.
04/10/2019The policy has been reviewed and issued to communicate the Company’s continuing position on Abortion.
03/14/2018The policy has been reviewed and issued to communicate the Company’s continuing position on Abortion.
02/22/2017This version of the policy will become effective 02/22/2017.

The policy has been reviewed and issued to communicate the Company’s continuing position on Abortion. The intent of the policy remains unchanged.

The following ICD-10 CM code has been added to this policy: Z33.2.


Revisions from MA11.010
3/30/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on abortion.
01/07/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Abortion.
01/01/2015This is a new policy.






Version Effective Date: 02/22/2017
Version Issued Date: 02/22/2017
Version Reissued Date: 04/09/2020