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December 2016 Texas Medicaid Provider Procedures Manual

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook : 3 Obstetric Services : 3.1 *Services, Benefits, Limitations, and Prior Authorization : 3.1.12 Fetal Surgery

The following procedure codes may be submitted for fetal surgery:
Fetal surgery procedures require prior authorization.
Prior authorization requests must be submitted on a Special Medical Prior Authorization (SMPA) Request Form to the SMPA department.
Refer to:
Procedure codes S2401, S2402, S2403, S2405 and S2409 may be authorized for Texas Medicaid only when the hospital is a member of the North American Fetal Therapy Network (NAFTNet).
The pediatric surgeon for procedure codes S2401, S2402, S2403, S2405, or S2409 must submit documentation which includes:
A clear description of the fetal malformation(s). The malformation(s) must interfere with the in utero organ development and fetal survival and have potential fatal consequences before or after birth
Evidence that in utero correction of the fetal congenital malformation(s) results in a clinical outcome that is better than that which would be seen in expectant management
Umbilical cord occlusion (procedure code 59072) may be considered when all the following is documented:
Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome (procedure code S2411) may be considered when all the following are documented:

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