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Obstetrical Ultrasonography - Oxford Health Plans

UnitedHealthcare Oxford Clinical Policy Obstetrical Ultrasonography . Policy Number: RADIOLOGY T2 Effective Date: December 1, 2017. Table of Contents Page Related Policy INSTRUCTIONS FOR USE .. 1 Radiology Procedures Requiring Precertification for CONDITIONS OF 1 eviCore healthcare Arrangement BENEFIT CONSIDERATIONS .. 2. COVERAGE RATIONALE .. 2. APPLICABLE CODES .. 3. BACKGROUND .. 4. REFERENCES .. 4. POLICY HISTORY/REVISION INFORMATION .. 5. INSTRUCTIONS FOR USE. This Clinical Policy provides assistance in interpreting Oxford benefit Plans . Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members.

The fourth and subsequent obstetrical ultrasound procedure per Member per pregnancy performed by a participating provider as outlined are subject to utilization review (pre-certification) by eviCore healthcare. Oxford has engaged eviCore healthcare to perform initial reviews of requests for pre-certification and Medical necessity reviews.

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