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Ultrasound in Pregnancy Policy

Fecha: 27/04/26

Dear Provider,

Thank you for your continued partnership with Ambetter from Sunflower Health Plan. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of the revision to existing policies Ambetter will be implementing effective June 01, 2026.

Policy Number

Policy Name

Policy Description

Lines of Business

CP.MP.38

Ultrasound in Pregnancy

This policy outlines the medical necessity criteria for ultrasound use in pregnancy. Ultrasound is the most common fetal imaging tool used today. Ultrasound is accurate at determining gestational age, fetal number, viability, and placental location and is necessary for many diagnostic purposes in obstetrics. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered. Ultrasound exams should be conducted only when indicated and must be appropriately documented.

AM Marketplace

ABS Commercial

Policy Updates and Reason

Coding changes bring policy into alignment with other payer policies. Changes allow payment for 76805 if billed for a second time within a rolling six months [this is the timeframe for the frequency limit that is currently in place for this code] of being billed on a previous claim, if billed by a different TIN than the previous claim with 76805. Add the following ICD-10 codes as payable with CPT code 76811: A93.0, O35.0XX1, O35.0XX2, O35.0XX3, O35.0XX4, O35.0XX5, O35.0XX9, O35.1XX0, O35.1XX1, O35.1XX2, O35.1XX3, O35.1XX4, O35.1XX5, O35.1XX9

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.

If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative or call Provider Services at 1-844-518-9505 (TTY 711).

Ambetter from Sunflower Health Plan is underwritten by Celtic Insurance Company, which is a Qualified Health Plan issuer in the Kansas Health Insurance Marketplace. ©2026 Celtic Insurance Company. All rights reserved.