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Billing codes
76801

PAYER POLICY CHANGES

76801 Insurance Policy Changes

CPT 76801, in plain terms, covers An ultrasound exam of a pregnant person carrying one baby before 14 weeks of pregnancy. CPT 76801 is referenced in 13 tracked payer policy changes from Priority Health, Arkansas Medicaid, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 76801 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 76801 on AAPC

Priority Health · Effective Dec 14, 2026Medium impact
Oct. 2026 billing policy updates
Priority Health updated multiple billing policies effective immediately and December 14, 2026. Two policies with December 14, 2026 effective dates require attention: Infusion Services Supplies (#041) clarifies that disposable delivery systems are non-covered, and Pelvic and Transvaginal Ultrasound (#056) adds new denials for CPT codes 76801, 76856, and 76857 when billed with 76817 or 76830 due to overlapping ultrasound services. Remaining policies represent current system setup with organizational updates to manual sections and coding guidance.
Arkansas Medicaid · Effective Sep 1, 2026High impact
Limitation Restrictions Removed for Non-Stress Tests and Ultrasounds
Effective September 1, 2026, Arkansas Department of Human Services removed prior authorization limitations for non-stress tests (CPT 59025) and fetal ultrasounds (CPT 76801-76828). Providers can now bill these procedures without hitting the previous two-per-nine-month-period cap, but must maintain documentation supporting medical necessity for all claims, which remain subject to retrospective review and recoupment.
Independence Blue Cross · Effective Mar 2, 2026High impact
MA00.057, Multiple Procedure Payment Reduction (MPPR) Guidelines for Transvaginal and Transabdominal Ultrasounds
Independence Blue Cross Medicare Advantage has implemented a new Multiple Procedure Payment Reduction (MPPR) policy effective March 2, 2026, requiring that when both transvaginal and transabdominal ultrasounds are performed on the same patient on the same date of service, the highest-allowance procedure is reimbursed at 100% and all subsequent procedures at 50% of contracted rates. Billing teams must ensure these procedures are reported on a single claim and apply the 50% reduction to secondary ultrasound codes.
Independence Blue Cross · Effective Mar 2, 2026High impact
MA00.057, Multiple Procedure Payment Reduction (MPPR) Guidelines for Transvaginal and Transabdominal Ultrasounds
Independence Blue Cross Medicare Advantage implemented a new Multiple Procedure Payment Reduction (MPPR) policy effective 03/02/2026 that reduces reimbursement to 50% for secondary transvaginal and transabdominal ultrasounds performed on the same date of service. The highest-allowance procedure receives 100% reimbursement; all subsequent procedures receive 50%. This applies to both obstetric and non-obstetric ultrasounds billed by the same provider or within the same facility on a single claim.
Independence Blue Cross · Effective Mar 2, 2026High impact
00.01.72, Multiple Procedure Payment Reduction (MPPR) Guidelines for Transvaginal and Transabdominal Ultrasounds
Independence Blue Cross implemented a new Multiple Procedure Payment Reduction (MPPR) policy effective March 2, 2026, that reduces reimbursement to 50% for secondary transvaginal or transabdominal ultrasound procedures when both are performed on the same patient by the same provider on the same date of service. Only the highest-allowance procedure receives 100% reimbursement; all subsequent procedures receive 50% payment.
Independence Blue Cross · Effective Mar 2, 2026Medium impact
00.01.72, Multiple Procedure Payment Reduction (MPPR) Guidelines for Transvaginal and Transabdominal Ultrasounds
Independence Blue Cross implemented new Multiple Procedure Payment Reduction (MPPR) guidelines effective March 2, 2026, that reduce reimbursement to 50% for secondary transvaginal and transabdominal ultrasounds performed on the same date of service. Billing teams must ensure both procedures are reported on a single claim and apply the hierarchy where the highest-allowance code is paid at 100% and subsequent codes at 50%. Add-on codes and Modifier 51 exempt codes are excluded from this reduction.
Connecticut Medicaid (HUSKY Health) · Effective Jan 1, 2026Medium impact
2026.16 - Updates to the Obstetric (OBS) and Facility Obstetric (FTO) Rate Types
Connecticut Medicaid (HUSKY Health) increased reimbursement rates for obstetric surgical, radiology, and office services under OBS and FTO rate types to 120% of 2025 Medicare physician fee schedule, effective retroactively to January 1, 2026. Claims meeting the increased rates will be automatically adjusted on April 24, 2026.
Maryland Medicaid · Effective Jul 1, 2025Medium impact
Medicaid Coverage for Radiological and Imaging Services Provided by Certified Nurse Practitioners
Effective July 1, 2025, Maryland Medicaid now reimburses Certified Nurse Practitioners (CRNPs) for interpretation of specific radiological and imaging services. Billing teams must update systems to recognize CRNPs as eligible providers for 13 allowable CPT codes across chest X-rays, abdominal X-rays, obstetric ultrasounds, and radiotherapy planning. This applies to both fee-for-service and HealthChoice managed care organizations in Maryland.
Maryland Medicaid · Effective Jul 1, 2025Medium impact
PT 07-26: Medicaid Coverage for Radiological and Imaging Services Provided by Certified Nurse Practitioners
Maryland Medicaid now allows certified nurse practitioners to interpret and bill for specific radiological and imaging services including chest X-rays, abdominal X-rays, obstetric ultrasounds, and other imaging studies. This expands billing opportunities for practices with CRNPs providing these interpretation services.
Aetna · Identified Oct 5, 2026Medium impact
Transvaginal Ultrasonography (CPB 0530, reviewed 2026-08-20)
Aetna's Clinical Policy Bulletin 0530 covers transvaginal ultrasonography (CPT 76817 and 76830) when selection criteria are met. Covered indications include assessment of fetal viability and gestational age in the first trimester, assessment of pelvic masses, abnormal uterine bleeding, monitoring of follicular development during infertility therapy, ectopic pregnancy, vasa previa, suspected endometriosis, and post-menopausal bleeding. The policy considers TVUS experimental, investigational or unproven for screening for endometrial, ovarian or other gynecologic cancers and for preoperative prediction of lymph node metastasis in cervical cancer.
Aetna · Identified Aug 18, 2026Medium impact
Transvaginal Ultrasonography (CPB 0530, reviewed 2025-08-25)
Aetna's Clinical Policy Bulletin 0530 covers transvaginal ultrasonography (TVUS), and its policy history shows a last review date of 08/20/2026. Aetna considers TVUS medically necessary for indications including assessment of fetal viability and gestational age in the first trimester when viability is uncertain, assessment of a pelvic mass, evaluation of abnormal uterine bleeding, diagnosis of ectopic pregnancy, evaluation of pelvic pain of suspected gynecologic origin, evaluation of infertility, guidance during embryo transfer, and verifying IUD position when the string is not visible. Aetna considers TVUS experimental, investigational or unproven for screening for endometrial cancer, ovarian cancer or other gynecologic cancers, and for preoperative prediction of lymph node metastasis in cervical cancer. Pelvic ultrasound is considered clinically integral to the transvaginal examination and does not warrant separate reimbursement.
Aetna · Identified Aug 14, 2026Medium impact
Ultrasound for Pregnancy (CPB 0199, reviewed 2026-03-24)
Detailed fetal anatomic ultrasound (CPT 76811) is medically necessary for listed indications, including known or suspected fetal anatomic or genetic abnormalities, pregnancies resulting from in vitro fertilization (IVF), obesity with a pre-pregnancy body mass index of 30 kg/m2 or more, known or suspected Zika virus exposure, and a previous pregnancy with a fetus that had an omphalocele or other ultrasound detectable congenital anomaly associated with an elevated risk of recurrence. Ultrasounds done solely to determine fetal sex or to give parents a view and photograph of the fetus are not medically necessary, and more than one detailed fetal anatomic ultrasound in the first trimester or more than one in the second semester is considered not medically necessary. A limited duplex scan (CPT 93976) is medically necessary for listed obstetric indications such as vaginal bleeding in the second or third trimester, suspected placenta accreta spectrum, and suspected placental abruption, while a complete duplex scan (CPT 93975) during pregnancy is considered experimental, investigational, or unproven, and 3D and 4D fetal ultrasounds are not supported because of a lack of evidence that they alter management over standard two-dimensional ultrasound.
Aetna · Identified Oct 8, 2026Low impact
Prenatal Care Provided by Primary Care Physicians (CPB 0047, reviewed 2026-10-06)
Aetna reviewed its Clinical Policy Bulletin 0047 on prenatal care provided by primary care physicians on October 6, 2026, but the text provided does not say what changed. The policy still sets the conditions under which a family physician can provide only prenatal care to an Aetna member, including coordination with a participating obstetrician, Healthy Chapters enrollment and specific referral timing.

Watch 76801

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REFERENCE DATA

Payers with rules3

Payers requiring prior auth3

CountyCare Health Plan · Effective April 23, 2026
Prior authorization required
CountyCare Prior Authorization Look-Up Tool (All Codes)
CalViva Health · Effective December 31, 2025
Prior authorization required
CalViva Health CMS-0057-F prior authorization requirements
Community Health Plan of Imperial Valley · Effective December 31, 2025
Prior authorization required
Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements

FREQUENTLY ASKED QUESTIONS

Does CalViva Health require prior authorization for 76801?

CalViva Health lists 76801 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Community Health Plan of Imperial Valley require prior authorization for 76801?

Community Health Plan of Imperial Valley lists 76801 on Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does CountyCare Health Plan require prior authorization for 76801?

CountyCare Health Plan lists 76801 on CountyCare Prior Authorization Look-Up Tool (All Codes) for medicaid managed plans (list dated April 23, 2026). Verify with the payer before scheduling.

What insurance policy changes affect CPT 76801?

There are 13 tracked policy changes affecting CPT 76801, including updates from Priority Health, Arkansas Medicaid, Independence Blue Cross. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 76801?

Payers that have issued tracked updates for CPT 76801 include: Priority Health, Arkansas Medicaid, Independence Blue Cross, Connecticut Medicaid (HUSKY Health), Maryland Medicaid, Aetna.

How do I get notified when CPT 76801 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 76801. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 76801?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

See every payer rule for 76801

Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 76801 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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Oct. 2026 billing policy updates

Limitation Restrictions Removed for Non-Stress Tests and Ultrasounds

MA00.057, Multiple Procedure Payment Reduction (MPPR) Guidelines for Transvaginal and Transabdominal Ultrasounds

MA00.057, Multiple Procedure Payment Reduction (MPPR) Guidelines for Transvaginal and Transabdominal Ultrasounds

00.01.72, Multiple Procedure Payment Reduction (MPPR) Guidelines for Transvaginal and Transabdominal Ultrasounds

00.01.72, Multiple Procedure Payment Reduction (MPPR) Guidelines for Transvaginal and Transabdominal Ultrasounds

2026.16 - Updates to the Obstetric (OBS) and Facility Obstetric (FTO) Rate Types

Medicaid Coverage for Radiological and Imaging Services Provided by Certified Nurse Practitioners

PT 07-26: Medicaid Coverage for Radiological and Imaging Services Provided by Certified Nurse Practitioners

Transvaginal Ultrasonography (CPB 0530, reviewed 2026-08-20)

Transvaginal Ultrasonography (CPB 0530, reviewed 2025-08-25)

Ultrasound for Pregnancy (CPB 0199, reviewed 2026-03-24)

Prenatal Care Provided by Primary Care Physicians (CPB 0047, reviewed 2026-10-06)

Prior authorization required

Prior authorization required

Prior authorization required

Does CalViva Health require prior authorization for 76801?

Does Community Health Plan of Imperial Valley require prior authorization for 76801?

Does CountyCare Health Plan require prior authorization for 76801?

What insurance policy changes affect CPT 76801?

Which payers have updated policy for CPT 76801?

How do I get notified when CPT 76801 policy changes?

Why do payers change policies for CPT 76801?