News
Ultrasound in Pregnancy (CP.MP.38)
Fecha: 11/03/26
Thank you for your continued partnership with Ambetter. 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 5/15/2026.
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 Medicaid AM Marketplace XL Medicaid 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.