Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
A 31-year-old female enrollee has requested reimbursement for evaluation of arterial inflow and 
venous  outflow  of  abdomen,  retroperitoneum,  scrotal  contents  and/or  pelvic  organs  and 
detailed  fetal  ultrasound,  fetal  doppler  echocardiography  and  umbilical  artery  doppler 
velocimetry on 3/11/22 and 5/10/22. The Health Insurer has denied this request and reported 
that the services at issue were investigational for the evaluation of the enrollees high risk 
pregnancy.  The  physician  reviewer  found  that  Uterine  artery  Dopplers  and  fetal 
echocardiography on 3/11/22 at 12 weeks of gestation were not likely to be more beneficial for 
the evaluation of the patients medical condition than standard, routine ultrasounds for fetal 
growth and development and prenatal care. Uterine artery Doppler screening of high-risk women 
such as women with a history of chronic hypertension or preeclampsia, prior fetal growth 
restriction, or stillbirth, with singleton gestations may identify those at substantially increased 
risk for adverse pregnancy outcomes. Abnormal testing in these women could potentially lead to 
increased surveillance, including earlier and more frequent assessment of fetal growth and 
maternal clinical condition, and interventions that might improve clinical outcomes. Normal 
Doppler studies could potentially lead to a reduction in such testing and interventions. However, 
further study is needed to determine which high-risk conditions are amenable to such screening, 
what testing regimen is optimal for a normal or abnormal test in these women, and what 
interventions based on these findings will improve pregnancy outcomes. Currently, there is a lack 
of evidence supporting routine screening with uterine artery Doppler in any particular group of 
patients. Assessment of uterine artery flow in second trimester has yielded more consistent 
results than in the first trimester, with performance at 18 to 20 weeks' gestation being a 
reasonable approach and some evidence that repeating the tests at 24 to 26 weeks may add 
further benefit. In this case, 12 weeks was the wrong gestational age to perform a uterine 
Doppler assessment. The ACOG notes regarding antepartum fetal surveillance that there is no  evidence that umbilical artery Doppler velocimetry provides information about fetal well-being 
in a fetus with normal growth. Similarly, 12 weeks was not the correct gestational age for a fetal 
echocardiogram nor was there a clinical indication for this study. The American Institute of 
Ultrasound in Medicine  (AIUM) notes that fetal echocardiography is commonly performed 
between 18 and 22 weeks gestational age, although some cardiac structures may be better 
visualized  before  or  after  this  period.  The  AIUM  further  notes  that  indications  for  fetal 
echocardiogram include pre-gestational, not gestational, diabetes, a condition that the patient 
would not have been diagnosed at 12 weeks. Regarding the umbilical artery Doppler and 
biophysical profile done on 5/10/22 at 21 weeks, both these tests of fetal well-being are usually 
performed in the third trimester. The ACOG notes that initiating antepartum fetal testing at 32 
weeks of gestation or later is appropriate for most at-risk patients. Additionally, umbilical artery 
Doppler studies are a technique of fetal surveillance for growth-restricted fetuses, based on the 
observation that flow velocity waveforms in the umbilical artery of normally growing fetuses 
differ from those of growth-restricted fetuses. In this case, the records did not document that 
the patients fetus was  growth restricted. Therefore, evaluation of arterial inflow and venous 
outflow of abdomen, retroperitoneum, scrotal contents and/or pelvic organs and detailed fetal 
ultrasound, fetal doppler echocardiography and umbilical artery doppler velocimetry on 3/11/22 
and 5/10/22 was not likely to have been more beneficial for evaluation of the patients condition 
than any available standard therapy.