Medical Policy Bulletin
Title: Elective Abortion
Policy #: 11.06.02e
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.
The intent of this policy is to communicate the Company's coverage position for elective abortion, when the member's contract provides a benefit for this service.
For information on policies related to this topic, refer to the Cross References Table in this policy.
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.
The medications and the guidelines you can obtain from the medicare policy. No tfurnishe dhere because it is not the part of our discussion at present).
The following procedures are used in surgical abortion:
• Dilation and curettage (D&C)
A procedure in which the cervix is gently opened and a loop-shaped instrument is inserted into the uterus to scrape the inner lining.
• Dilation and evacuation (D&E)
A procedure in which the cervix is dilated and the uterine contents are removed by suction.
• Hypertonic saline or prostaglandin infusion
Intra-amniotic infusion of these agents stimulates uterine contractions and induces abortion.
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 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.
An elective abortion is a covered service according to the criteria specified in the member's group benefit contract and according to applicable state laws.
Coverage limitations for elective abortion may vary by product or group. Therefore, individual member benefits must be verified.
The coverage for Medicare Advantage members is as follows:
• Elective abortions are excluded under the Original Medicare program, except in instances of rape or incest, or if a woman has a physical disorder, physical injury, or physical illness (including a life-endangering condition caused by the pregnancy itself) that would, as certified by a physician, place the woman in danger of death unless the abortion is performed.
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.
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.
This policy is consistent with Original Medicare's coverage criteria for Medicare Advantage members. The Company's payment methodology may differ from Medicare.
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 physician’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 (eg, 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 indications approved by the US Food and Drug Administration (FDA):
• Mifepristone (Mifeprex™) in combination with misoprostol
o Mifepristone (Mifeprex™) has been approved by the FDA for use in combination with misoprostol for the termination of early pregnancy, which the FDA defines as 49 days or less, counting from the first day of the last menstrual period.
o 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 physician who is registered with the manufacturer; it is not available at a local retail pharmacy. According to the FDA requirements for the prescriber, only physicians 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 are permitted to dispense the drug.
o Two days after taking mifepristone (Mifeprex™), the pregnant woman must return to the physician's office to receive misoprostol. Rh-negative women should also receive Rh immune globulin (RhoGAMÂ®) at this time, or make arrangements to receive it within three days of a successful elective medical abortion. Misoprostol is a prostaglandin that causes cramping and bleeding, which may be severe enough to require surgical intervention and/or a blood transfusion.
o Fourteen days after taking misoprostol, there should be a follow-up visit to the physician 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:
o 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.
o The office visit for administration of mifepristone (Mifeprex™).
o The office visit two days after administration of mifepristone (Mifeprex™) for administration of misoprostol.
o The office visit 14 days after the administration of misoprostol and possibly another ultrasound to confirm that a complete abortion has occurred.
o Possible surgical intervention if a complete abortion has not occurred.
• The use of mifepristone (Mifeprex™) for medical abortion is contraindicated in the following circumstances:
o Confirmed or suspected ectopic (tubal) pregnancy
o Undiagnosed adnexal mass
o The presence of an intrauterine device (IUD)
An IUD should be removed prior to the administration of mifepristone (Mifeprex™)
o Chronic adrenal failure
o Concurrent long-term corticosteroid therapy
o History of allergy to mifepristone (Mifeprex™), misoprostol, or other prostaglandin
o Hemorrhagic disorders or concurrent anticoagulant therapy
o Inherited porphyrias
o 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
o 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 physician 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 criteria was met.
American College of Obstetricians and Gynecologists (ACOG). ACOG Patient Education Pamphlet. Induced abortion. [ACOG Web site]. Available at: http://www.acog.org/publications/pat...tion/bp043.cfm. Accessed February 3, 2011.
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...=BAABAAAAAAAA&. Accessed February 3, 2011.
Company benefit contracts
Danco Laboratories, LLC. MifeprexÂ® (Mifepristone). [Danco Web site]. 07/18/05. Available at: http://www.earlyoptionpill.com. Accessed February 3, 2011.
Overview of State Abortion laws. Guttmacher Institute. February 1, 2011. Available at:
http://www.guttmacher.org/statecente...s/spib_OAL.pdf. Accessed February 3, 2011.
US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Mifeprex (mifepristone) information. [FDA Web site]. Original: 11/15/04. (Revised: 08/29/07). Available at:
http://www.fda.gov/Drugs/DrugSafety/.../ucm111323.htm. Accessed February 3, 2011.
US Food and Drug Administration (FDA). Medication guide: MifeprexÂ®. [FDA Web site]. 11/12/04. Available at: http://www.accessdata.fda.gov/drugsa...0-medguide.pdf. Accessed February 3, 2011.
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.
Code System Code Number(s) and Narrative(s)
CPT 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866, 59200
ICD Procedure N/A
ICD Diagnosis See Attachment A of the medical policy for eligible ICD-9 codes.
HCPCS Level II S0190: Mifepristone, oral, 200 mg (may be billed up to 3 times each procedure; total of 600 mg)
S0191: Misoprostol, oral, 200 mcg
J8610: Methotrexate, oral, 2.5 mg
J9250: Methotrexate sodium, 5 mg
J9260: Methotrexate sodium, 50 mg
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
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 Revenue Codes N/A
Associated attachments to Policy 11.06.02e: Elective Abortion
Attachment A : Elective Abortion
Description: ICD-9 codes that are eligible to be reported for elective abortion.
Cross Reference Policies
00.09.01d: Direct Access Obstetrics/Gynecology (OB/GYN)
Version Effective Date: 03/10/2008
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