Medical Policy
Effective Date:09/08/2004 Title:Chorionic Villus Sampling
Revision Date:10/01/2015 Document:BI072:00
CPT Code(s):59015, 76945, 88235, 88267, 88291
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Chorionic Villus Sampling (CVS) is covered as an alternative to amniocentesis when early pregnancy genetic screening is medically indicated due to advanced maternal age, significantly increased risk of fetal chromosome abnormality or a history of genetically abnormal offspring.  All other uses for CVS require preauthorization.

2)    See also the policy on Amniocentesis (BI017).
Medical Statement

CVS is appropriate when indicated for medical reasons.  There are several problems with fetal development for which CVS is necessary for proper management of the pregnancy. Repeat testing is subject to additional clinical documentation of need. 

 

Elective CVS is not covered for determination of fetal gender or as part of routine prenatal care.

 

The only genetic abnormality testing covered in the absence of a family history (pedigree indication) is CVS and chromosome karyotyping.  Karyotyping is covered only when the results are to be used to affect the management of the pregnancy. 

 

1)    Chorionic Villus Sampling (CVS) will be covered for the following conditions:

a)    Mother is 35 years of age or older, OR

 

b)    Abnormal fetal ultrasound examination reveals signs proven to be associated with fetal genetic abnormalities.

 

c)     Abnormal results from first trimester screening (combined maternal serum screening and nuchal translucency).

 

2)    In addition, Chorionic Villus Sampling will be covered, if pre-authorized in the following circumstances:

a)    There is a previous offspring with a chromosomal abnormality, OR

 

b)    There is a family history of genetic defects that can be diagnosed with CVS, OR

 

c)     The parents’ ethnic background and/or family history indicate certain autosomal recessive diseases; OR

 

d)    There is a need to determine fetal sex when there is a family history of serious x-linked condition for which intrauterine diagnosis is not available.

 

e)    One of the parents of the pregnancy is a known carrier of a chromosomal abnormality; OR

 

f)      These parents have had a child with a syndromic presentation and unknown diagnosis and the child is unable to be tested, OR

 

g)    There is a need to test the  pregnancy for an infectious disease because:            

i)       There are clinical signs and symptoms of a current infection in the mother; OR

ii)     There is serologic evidence of a current or recent infection in the mother (with or without clinical signs); OR

iii)    There are fetal abnormalities identified on ultrasound indicating an increased risk for a congenital infection

 

3)    See also the policy on Amniocentesis (BI017).

 

Codes Used In This BI:

 

59015           Chorion Biopsy

76945           Echo Guide Villus Sampling

88235           Tissue Culture Placenta

88267           Chromosome Analys Placenta

88291           Cyto/Molecular Report
Limits

1)    CVS must be performed by a specialist in Maternal-Fetal Medicine.

2)    CVS cannot be used for the diagnosis of neural tube defects, which require analysis of amniotic fluid alpha fetal protein. 

Reference
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Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.