Medical Policy

3-DIMENSIONAL AND 4-DIMENSIONAL FETAL ULTRASOUND (REQUIRES PREAUTHORIZATION)

IV.79

IV.79 3-DIMENSIONAL AND 4-DIMENSIONAL FETAL ULTRASOUND (REQUIRES PREAUTHORIZATION)

Description

Ultrasound is commonly performed during pregnancy, either to assess the gestational age or to evaluate fetal size, position, heartbeat, congenital malformations, suspected multiple fetuses or placental abnormalities. Two-dimensional ultrasound is most commonly used. Three-dimensional (3-D) and four-dimensional (4-D) ultrasound involve computer generated images viewed on a video monitor that provide more detail and can produce almost life-like images of the fetus.

Dates

Original Effective
02-23-2011
Last Review
08-07-2024
Next Review
08-11-2025

Policy

The use of 3-D or 4-D fetal ultrasound for routine prenatal screening is investigational.

Quick Code Search

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Procedure

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Diagnosis

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Codes

Full Description

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation

Full Description

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation

Full Description

Unlisted diagnostic radiographic procedure

References

2010 Kurak, A. et al. The potential of 4D sonography in the assessment of fetal neurobehavior – multicentric study in high-risk pregnancies. J. Print. Med. 2010;38:77-82.
2008 Fuchs, F., et al. Prenatal diagnosis of a patent urachus cyst with the use of 2D, 3D, 4D ultrasosund and fetal magnetic resonance imaging. Fetal Diagn Ther 2008;24:444-447.
2008 Rizzo, G., et al. Examination of the fetal heart by four-dimensional ultrasound with spatiotemporal image correlation during routine second-trimester examination: the three-steps technique. Fetal Diagn Ther 2008;24:126-131.
2008 Wong, H., et al. Viewing of the soft and the hard palate on routine 3D ultrasound sweep of the fetal face - a feasibility study. Fetal Diagn Ther 2008;24:146-154.
2009 Brett, S., et al. Individual ovarian volumes obtained from 2-dimensional and 3-dimensional ultrasound lack precision. Reproductive BioMedicine Online, Vol. 18, No. 3, 2009, 348-351.
2009 Gindes, L., et al. Three and four dimensional ultrasound: a novel method for evaluating fetal cardiac anomalies. Prenat Diagn 2009; 29: 645-653.
2009 Hata, T., et al. Three dimensional volume rendered imaging of embryonic brain vesicles using inversion mode. J. Obstet. Gynaecol. Res. Vol. 35, No. 2: 258-261, April 2009.
2009 Hermann, N., et al. Prenatal 3D ultrasound diagnostics in cleidocranial dysplasia. Fetal Diagn Ther 2009;25:36-39
2009 Lecart, M., et al. In vitro in-stent restenoses evaluated by 3D ultrasound. Med. Phys. 36 (2), February 2009.
2009 Rousian, M., et al. Early pregnancy volume measurements: validation of ultrasound techniques and new perspectives. BJOG 2009; 116:278-285.
2010 Duckelmann, A., et al. Three-dimensional ultrasound in evaluating the fetus. Prenat Diagn 2010; 30: 631-638.
2010 Kurjak, A., et al. The potential of 4D sonography in the assessment of fetal neurobehavior - multicentric study in high-risk pregnancies. J. Perinat. Med. 38 (2010) 77-82.
2021 Wataganara T, Rekhawasin T, Sompagdee N, et al. A 10-year retrospective review of prenatal applications, current challenges and future prospects of three-dimensional sonoangiography. Diagnostics (Basel). 2021; 11(8):1511.
2024 Mazzone E, Kadji C, Cannie MM, et al. Prediction of large-for-gestational age at 36 weeks' gestation: two-dimensional ultrasound vs three-dimensional ultrasound vs magnetic resonance imaging. Ultrasound Obstet Gynecol. 2024; 63(4):489-496.
2023 Zhang L, Jin TL. Predictive value and accuracy of prenatal four-dimensional color ultrasound for fetal abnormal development. Medicine (Baltimore). 2023 Aug 11;102(32):e34553.