This version of the policy will become effective on 08/12/2019. The policy has been updated to include septostomy as not medically necessary, and cervical pessary and cervical cerclage as experimental/investigational, respectively, for the treatment of Twin-Twin Transfusion Syndrome.
The following ICD-10 codes have been added to this policy: O43.029.
The following HCPCS codes have been added to this policy: S2411, A4561, A4562.
The following CPT codes have been added to this policy: 57160, 59320, 59325, 59897.
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.
In the subpopulation of women with short cervical length and TTTS, cervical pessary and cervical cerclage have been proposed as potential treatment strategies to combat premature birth. Cervical pessary as TTTS treatment involves placement of a round silicone device (pessary) at the opening of the cervix to block passage of the fetus. Cervical cerclage is a suture sewn into and around the cervix for the prevention of miscarriage and premature labor. Available evidence for these approaches is very limited and further investigation is required before making any determination regarding their respective use in clinical practice. Currently, neither cervical pessary nor cervical cerclage are recommended for management of TTTS.
The alternative to prenatal intervention is conservative management, which is associated with a fetal mortality rate between 90 percent and 100 percent.
WHEN USED FOR THE TREATMENT OF TWIN-TWIN TRANSFUSION SYNDROME (TTTS) THE FOLLOWING CODES ARE CONSIDERED TO BE EXPERIMENTAL/ INVESTIGATIONAL
57160, 59320, 59325
NOT MEDICALLY NECESSARY
THE FOLLOWING CODE IS USED TO REPRESENT SEPTOSTOMY WHEN USED FOR THE TREATMENT OF TWIN-TWIN TRANSFUSION SYNDROME (TTTS)
O43.021 Fetus-to-fetus placental transfusion syndrome, first trimester
O43.022 Fetus-to-fetus placental transfusion syndrome, second trimester
O43.023 Fetus-to-fetus placental transfusion syndrome, third trimester
O43.029 Fetus-to-fetus placental transfusion syndrome, unspecified trimester