Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Elective Abortion

Policy #:11.06.02i

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

An elective abortion is a covered service according to the criteria specified in the member's group benefit contract and according to applicable laws of the state in which the procedure is performed.

Coverage limitations for elective abortion may vary by product, group, or situation. Therefore, individual member benefits must be verified.

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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, elective abortion is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

THE FOLLOWING GUIDELINES APPLY TO ALL LINES OF BUSINESS

First-trimester (less than or equal to 14 weeks gestation) abortion procedures are typically performed in a professional provider’s office or in a freestanding outpatient facility that provides abortion services, except under unusual conditions such as, but not limited to:
  • Requirement for special anesthesia (e.g., general, spinal)
  • Need for genetic studies on the products of conception
  • Anatomical considerations
  • Medical conditions for which the usual setting is potentially dangerous

Procedures performed at or after the first trimester are typically performed in an ambulatory surgery center or a short procedure unit setting.

Under the provision of the Direct Access program, health maintenance organization (HMO) members are not required to obtain a primary care physician (PCP) referral in order to obtain abortion services.

The following guidelines regarding the use of mifepristone (Mifeprex™) in combination with misoprostol to induce medical abortions are consistent with the manufacturer's labeling and the regimen approved by the US Food and Drug Administration (FDA):
  • Mifepristone (Mifeprex™) in combination with misoprostol
    • Mifepristone (Mifeprex™) has been approved by the FDA for use in combination with misoprostol for the termination of intrauterine pregnancy through 70 days gestation, counting from the first day of the last menstrual period.
    • Mifepristone (Mifeprex™) is administered orally by a physician or a health care practitioner working under the supervision of a physician. The drug is available only in the office of a prescriber who is registered with the manufacturer; it is not available at a local retail pharmacy. According to the FDA requirements for the prescriber, the drug must be provided by or under the supervision of a physician who is able to assess the duration of the pregnancy, to diagnose ectopic pregnancies, and to provide surgical intervention or to arrange for a physician to provide for surgical intervention in the event of an incomplete abortion or severe bleeding.
    • One to two days after taking mifepristone (Mifeprex™), the pregnant woman takes the misoprostol tablets. Misoprostol is a prostaglandin that causes cramping and bleeding, which may be severe enough to require surgical intervention and/or a blood transfusion.
      • Rh-negative women should also receive Rh immune globulin (RhoGAM®) within three days of a successful elective medical abortion.
    • Seven to fourteen days after taking misoprostol, there should be a follow-up visit to the professional provider who prescribed the regimen to verify, by clinical examination or ultrasonography, that the pregnancy has been terminated. In most instances, complete lack of bleeding following treatment suggests a medical abortion failure (missed abortion), and surgical termination should follow.
  • Medical abortions performed using mifepristone (Mifeprex™) and misoprostol consist of the following:
    • A counseling session (if required by applicable state law) and ultrasound (if necessary) to date the pregnancy; both may be performed by the abortion provider.
      • HMO members in areas where there is a capitated radiology program are not required to use their PCP’s capitated radiology site for any ultrasound(s) required for this procedure but may have the ultrasound(s) performed in the abortion provider’s office.
    • The office visit for administration of mifepristone (Mifeprex™).
      • Rh-negative women should also receive Rh immune globulin (RhoGAM®) at a dose appropriate to the gestational age at which the abortion occurs.
    • The office visit 7-14 days after the administration of misoprostol and possibly another ultrasound to confirm that a complete abortion has occurred.
    • Possible surgical intervention if a complete abortion has not occurred.
  • The use of mifepristone (Mifeprex™) for medical abortion is contraindicated in the following circumstances:
    • Confirmed or suspected ectopic (tubal) pregnancy.
    • Undiagnosed adnexal mass.
    • The presence of an intrauterine device (IUD).
      • An IUD should be removed prior to the administration of mifepristone (Mifeprex™).
    • Chronic adrenal failure.
    • Concurrent long-term corticosteroid therapy.
    • History of allergy to mifepristone (Mifeprex™), misoprostol, or other prostaglandin.
    • Hemorrhagic disorders or concurrent anticoagulant therapy.
    • Inherited porphyrias.
    • When there is inadequate access to medical facilities equipped to provide emergency treatment of incomplete abortion, blood transfusions, and emergency resuscitation from the time of the first visit until discharge by the administering physician.
    • When a woman is unable to understand the effects of the procedure or to comply with its requirements.

For abortion services related to a pregnancy that is a result of rape or incest or is certified by a professional provider as life-threatening, the applicable Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code must be reported and appended with the appropriate modifier to identify that this criterion was met.

Description

Elective abortion is the voluntary expulsion or extraction of the products of conception from the uterus, which results in the termination of a pregnancy.

Elective abortion procedures can be performed for reasons such as, but not limited to, the following:
  • Maternal medical complications that could make continuation of pregnancy dangerous and/or potentially lethal for the pregnant woman
  • Maternal medical complications that could result in physical or psychological complications for the pregnant woman
  • Fetal complications (related to genetics/genetic history or anatomical or congenital causes)
  • Reduction of a multifetal gestation
  • Pregnancy as a result of rape or incest
  • The choice of the pregnant woman

Abortion procedures are performed up to varying gestational ages, depending on specific state legislation. Gestational age is defined as the number of days or weeks from the first day of the last menstrual period (menstrual age) or the number of weeks from the date of conception (conceptual age).

An elective abortion can be accomplished by either medical or surgical intervention.

MEDICAL ABORTION

The following medications are used in medical abortion:
  • Mifepristone (Mifeprex™) in combination with misoprostol
    Mifepristone (Mifeprex™) has been approved by the US Food and Drug Administration (FDA) for use in combination with misoprostol for the termination of intrauterine pregnancy through 70 days gestation, counting from the first day of the last menstrual period. Mifepristone (Mifeprex™) blocks the production of progesterone, a hormone needed to sustain pregnancy. This product is sometimes referred to by its laboratory name, RU-486.
  • Misoprostol (alone, or in combination)
    Misoprostol is an FDA-approved drug that is often used to treat stomach ulcers. When misoprostol is given off-label to a pregnant woman (usually by vaginal suppository) several days after receiving methotrexate, it stimulates uterine contractions and assists in the expulsion of an early pregnancy. Misoprostol may also be given off-label in combination with mifepristone (Mifeprex™) as noted above, or it may be used alone off-label in early pregnancy to induce abortion.
  • Methotrexate (in combination)
    Methotrexate is an FDA-approved drug that is used in the treatment of certain cancers and chronic diseases. It is also used off-label to treat an unruptured ectopic pregnancy, which occurs when a pregnancy develops outside of the uterus, usually in the Fallopian tubes. Methotrexate, when used early in pregnancy, prohibits the growth of cells, both embryonic and placental. Methotrexate, as noted above, may be used off-label in combination with misoprostol to induce abortion.
  • Dinoprostone (alone)
    Dinoprostone is an FDA-approved vaginal suppository form of prostaglandin (PGE2) for labor induction up to 28 weeks when fetal demise has occurred. It is also FDA-approved to induce abortion between 12 and 20 weeks.

SURGICAL ABORTION

The following procedures are used in surgical abortion:
  • Suction and curettage
    A procedure in which the cervix is dilated and the uterine contents are removed by suction and gentle scraping with a sharp looped instrument during the first trimester
  • Dilation and evacuation (D&E)
    A procedure in which the cervix is dilated and the uterine contents are removed by suction
    and gentle scraping with a sharp looped instrument after the first trimester.
  • Hypertonic saline or prostaglandin infusion
    Intra-amniotic infusion of these agents stimulates uterine contractions and induces abortion.
  • Hysterotomy
    Similar to a Cesarean section, incisions are made in the abdomen and uterus, and the fetus,
    placenta, and amniotic sac are removed. This method is generally used
    for upper second trimester pregnancies if chemical methods such as infusion of hypertonic saline or prostaglandin fail.

The choice of procedure depends on the gestational age of the pregnancy at the time the termination is planned, the pregnant woman's wishes, and her medical condition, in consultation with her health care provider.
References


American College of Obstetricians and Gynecologists (ACOG). ACOG Frequently asked questions special procedures: Dilation and curettage (D&C). [ACOG Web site]. February 2016. Available at: https://www.acog.org/Patients/FAQs/Dilation-and-Curettage-DandC. Accessed March 19, 2019.

American College of Obstetricians and Gynecologists (ACOG). ACOG Practice Bulletin #135: Second-Trimester Abortion. Obstet Gynecol. 2013; 121:1394–1406. Reaffirmed 2017.

American College of Obstetricians and Gynecologists (ACOG). ACOG Practice Bulletin #143: Medical Management of First-Trimester Abortion. Obstet Gynecol. 2014;123:676-92. Reaffirmed 2016.

American College of Obstetricians and Gynecologists (ACOG). ACOG Patient Education FAQs. Induced abortion. May 2015. [ACOG Web site]. Available at: http://www.acog.org/~/media/For%20Patients/faq043.pdf?dmc=1&ts=20120815T1056274371. Accessed March 19, 2019.

Company Benefit Contracts.

Danco Laboratories, LLC. Mifeprex® (Mifepristone). [Danco Web site]. ND. Available at: http://www.earlyoptionpill.com. Accessed March 19, 2019.

Danco Laboratories. Mifeprex ® (Mifepristone) Tablets, 200 mg. Patient Agreement. (Revised 3/29/2016). Available at: http://www.earlyoptionpill.com/wp-content/uploads/2016/03/Patient-Agreement-Form-March2016-1.pdf. Accessed March 19, 2019.

Dinoprostone vaginal suppository Prostin E2® [prescribing information]. New York, NY: Pfizer, Inc.; 2017. Available at https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/017810s019lbl.pdf. Accessed March 19, 2019.

Guttmacher Institute. Counseling and waiting periods for abortion. [Guttmacher Institute Web site]. March 01, 2019. Available at: https://www.guttmacher.org/state-policy/explore/counseling-and-waiting-periods-abortion . Accessed March 19, 2019.

Hammond C. Second trimester pregnancy termination: Dilation and evacuation. 12/06/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed March 19, 2019.

Hammond C. Second trimester pregnancy termination: Induction (medication) termination. 05/24/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed March 19, 2019.

Harwood B. First trimester medication abortion (termination of pregnancy). 02/11/2019. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed March 19, 2019.

Kulier R, Fekih A, Hofmeyr GJ, Campana A. Surgical methods for first trimester termination of pregnancy. Cochrane Database of Systematic Review. 2001, Issue 4.

Mifepristone. Micromedex® Healthcare Series. DrugDex®. [Micromedex® Web site]. Last modified: November 29, 2017. Available at: http://www.micromedex.com [via subscription only]. Accessed March 19, 2019.

Misoprostol tablets (Cytotec®) [prescribing information]. New York, NY: Pfizer, Inc.; 2016. Available at: http://labeling.pfizer.com/ShowLabeling.aspx?id=559. Accessed March 19, 2019.

National Abortion Federation Fact Sheet on Certified Nurse-Midwives, Nurse Practitioners, and Physician Assistants as Abortion Providers (Revised July 2007). Available at: https://prochoice.org/pubs_research/publications/downloads/cfc/CNM_NP_PA_factsheet.pdf. Accessed March 19, 2019.

National Abortion Federation. 2016 Clinical Policy Guidelines. Available at: https://5aa1b2xfmfh2e2mk03kk8rsx-wpengine.netdna-ssl.com/wp-content/uploads/2016-CPGs-web.pdf. Accessed March 19, 2019.

National Abortion Federation. 2018 Clinical policy guidelines for abortion care. Available at: https://5aa1b2xfmfh2e2mk03kk8rsx-wpengine.netdna-ssl.com/wp-content/uploads/2018_CPGs.pdf. Accessed March 19, 2019.

Overview of State Abortion laws. Guttmacher Institute. December 1, 2017. Available at: http://www.guttmacher.org/statecenter/spibs/spib_OAL.pdf. Accessed March 19, 2019.

Shannon C, Winikof B. Misoprostol as a single agent for medical termination of pregnancy. 12/03/2018. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed March 19, 2019.

Shih G, Wallace R. First-trimester pregnancy termination: Uterine aspiration. 09/21/2018. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed March 19, 2019.

Steinauer J. Overview of pregnancy termination. 06/07/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed March 19, 2019.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Mifeprex (mifepristone) information. [FDA Web site]. Original: 11/15/04. (Revised: 02/05/2018). Available at: https://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm111323.htm. Accessed March 19, 2019.

US Food and Drug Administration (FDA). Medication guide: Mifeprex®. [FDA Web site]. Rev 03/2016. Available at: http://www.fda.gov/downloads/Drugs/DrugSafety/UCM088643.pdf. Accessed March 19, 2019.

US Food and Drug Administration (FDA). Methotrexate Sodium for Injection. (Revised 10/2011). Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/011719s117lbl.pdf. Accessed March 19, 2019.

US Food and Drug Adminstration. (FDA). Labeling for Mifeprex®. 03/2016. [FDA Web site]. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/020687s020lbl.pdf. Accessed March 19, 2019.

Weeks AD, Fiala C, Safar P. Misoprostol and the debate over off-label drug use. BJOG. 2005;112:269–272.

World Health Organization. Safe abortion: technical and policy guidance for health systems. 2nd ed. Geneva, Switzerland: WHO; 2012. Available at: http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf. 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)

59200, 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)

See Attachment A of the medical policy for eligible ICD-10 codes.


HCPCS Level II Code Number(s)



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

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, 17-24 weeks

S2265 Induced abortion 25-28 weeks

S2266 Induced abortion 29-31 weeks

S2267 Induced abortion 32 weeks or greater


Revenue Code Number(s)

N/A


Misc Code

Modifier:

Append this modifier to the appropriate CPT or HCPCS code to indicate why the procedure was performed:

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


Coding and Billing Requirements


Cross References

Attachment A: Elective Abortion
Description: Diagnosis codes ICD-10




Policy History

11.06.02i
04/10/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on Elective Abortion.
10/01/2018Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

This policy has been identified for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 CM codes have been added to this policy:

O30.131, O30.132, O30.133, O30.139, O30.231, O30.232, O30.233, O30.239, O30.831, O30.832, O30.833, O30.839

Revisions from 11.06.02h:
03/14/2018This policy has undergone a routine review, and no revisions have been made.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: 04/10/2019

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