May 01, 2022

Coverage changes for prenatal ultrasounds

Starting July 1, 2022, there’s a new obstetrical ultrasound medical policy for UnitedHealthcare Individual Exchange plan members. We’ll make coverage determinations post-service, pre-pay based on the following:

  • Up to 3 prenatal ultrasounds per pregnancy, for CPT® codes 76801, 76802, 76805, 76810, 76811, 76812, 76815, 76816 and 76817, will be considered proven and medically necessary
  • Four or more ultrasounds will be considered proven and medically necessary for high-risk pregnancies, as described in the policy, when the treating provider will make therapeutic determinations based upon the results

Place of service
This policy applies to professional claims billed on a Health Care Finance Administration (HCFA) form with place of service 11 and 22.

This policy doesn’t apply to:

  • Prenatal ultrasounds rendered in an emergency room
  • Outpatient observation care
  • Inpatient hospital setting

Charging patients for non-covered services
Please note, you may only bill a member for services denied for lack of medical necessity if you’ve obtained written consent from the member prior to the service being rendered. Member consent will need to include an estimate of the charges and a statement of the reason you believe the service may not be covered. See the “Charging members for non-covered services” protocol in the UnitedHealthcare care provider administrative guide.

Contact your provider relations advocate.

CPT® is a registered trademark of the American Medical Association.