CPT 76811, in plain terms, covers A detailed ultrasound examination of a single baby during pregnancy to check development and health. CPT 76811 is referenced in 11 tracked payer policy changes from Arkansas Medicaid, Independence Blue Cross, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 76811 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 76811 on AAPC
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 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 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 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.
Ambetter from Meridian is updating its Ultrasound in Pregnancy policy (CP.MP.38) effective August 1, 2026. The policy now allows CPT 76805 to be billed a second time within a rolling six-month period if submitted by a different TIN than the previous claim, and adds 15 specific ICD-10 diagnosis codes as payable with CPT 76811 for fetal anomaly 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) 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.
Aetna considers the non-invasive fetal membranes rupture tests, including Actim PROM, AmniSure ROM, Chorioquick and the ROM Plus Fetal Membranes Rupture Test, experimental, investigational, or unproven for detecting preterm rupture of membranes and for all other indications. Aetna also considers the Biobeat Monitoring Platform, evaluation of vaginal microbiome profiles, fetal membrane imaging, functional placental MRI and amniotic fluid suPAR experimental, investigational, or unproven for their listed uses. CPT codes 84112, 74712 and 74713 are not covered for the indications listed.
Aetna's Clinical Policy Bulletin 0757 considers non-invasive fetal membranes rupture tests, including Actim PROM, AmniSure ROM, Chorioquick and the ROM Plus Fetal Membranes Rupture Test, experimental, investigational or unproven for detecting preterm rupture of membranes and all other indications. The same status applies to the Biobeat Monitoring Platform, evaluation of vaginal microbiome profiles, fetal membrane imaging, functional placental MRI for infection or inflammation in preterm PROM, and amniotic fluid suPAR for diagnosing fetal inflammatory response syndrome. The policy also lists specific CPT codes, including 84112 for cervicovaginal fluid amniotic protein evaluation, as not covered for the indications it lists.
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 considers asfotase alfa (Strensiq) medically necessary for perinatal/infantile-onset and juvenile-onset hypophosphatasia (HPP) when the member has signs or symptoms of HPP, onset before 18 years of age, and a diagnosis confirmed either by a known pathogenic ALPL gene variant or by skeletal abnormalities on imaging with a below-range serum alkaline phosphatase level and an elevated TNSALP substrate level. The drug must be prescribed by or in consultation with an endocrinologist, geneticist, or physician specializing in the treatment of metabolic bone disorders, and continuation requires improvement from baseline on at least one listed measure; all other indications are considered experimental, investigational, or unproven.
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