Vesicoamniotic shunting as a treatment of urinary tract obstruction may be considered medically necessary in fetuses under the following conditions:
Evidence of hydronephrosis due to bilateral urinary tract obstruction AND
Progressive oligohydramnios AND
Adequate renal function AND
No other lethal abnormalities or chromosomal defects.
Open in utero resection of malformed pulmonary tissue or placement of a thoracoamniotic shunt may be considered medically necessary under the following conditions:
Congenital cystic adenomatoid malformation or bronchopulmonary sequestration is identified; AND
The fetus is at 32 weeks of gestation or less AND
There is evidence of fetal hydrops, placentomegaly, and/or the beginnings of severe preeclampsia (ie, the maternal mirror syndrome) in the mother.
In utero removal of sacrococcygeal teratoma may be considered medically necessary under the following conditions:
The fetus is at 32 weeks of gestation or less AND
There is evidence of fetal hydrops, placentomegaly, and/or the beginnings of severe preeclampsia (ie, maternal mirror syndrome) in the mother.
In utero repair of myelomeningocele may be considered medically necessary under the following conditions:
The fetus is at less than 26 weeks of gestation AND
Myelomeningocele is present with an upper boundary located between T1 and S1 with evidence of hindbrain herniation.
In utero repair of myelomeningocele is considered investigational in the following situations:
Fetal anomaly unrelated to myelomeningocele OR
Severe kyphosis OR
Risk of preterm birth (eg, short cervix or previous preterm birth) OR
Maternal body mass index of 35 kg/m2 or more.
All other applications of fetal surgery are investigational, including but not limited to, temporary tracheal occlusion as a treatment of congenital diaphragmatic hernia or treatment of congenital heart defects.
