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MP 4.01.08 External Cephalic Version

 

Medical Policy    
Section
OB/Gyn Reproduction
Original Policy Date
3/31/96
Last Review Status/Date
Review by consensus/2:2003
Issue
2:2003
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.

 


 

Description

External version is the method of turning the fetus in the uterus to avoid a breech delivery. An intravenous infusion of ritodrine, a drug used to relax the uterus, is used during the external version to reduce complications associated with external cephalic version.

 


 

Policy

External version is considered medically necessary to avoid a breech delivery.

 


 

Policy Guidelines

No applicable information

 


 

Benefit Application

BlueCard/National Account Issues

External version may be included as an integral part of the global obstetrical fee. It is not to be billed as a separate procedure.

 


 

Rationale

A search of literature was completed through the MEDLINE database for the period of January 1992 through December 1995. The search strategy focused on references containing the following Medical Subject Headings:

– Fetal
 
– Ritodrine
 
– Version

Research was limited to English-language journals on humans.

 

Codes

Number

Description

CPT  59412  External cephalic version, with or without tocolysis 
ICD-9 Procedure  73.91  External version 
ICD-9 Diagnosis  652.10–652.13  Breech or other malpresentation successfully converted to cephalic presentation code range 
HCPCS  No Code   
Type of Service  OB/GYN 
Place of Service  Inpatient
 
Outpatient
 

 


 

Index

External cephalic version
Version, external cephalic

 


 

Policy History

Date Action Reason
3/31/96 Add to OB/Gyn section New policy
7/12/02 Replace policy Policy reviewed by consensus; new review date only
07/17/03 Replace policy Policy no longer scheduled for review