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)    Prenatal screening for trisomy is routinely offered to all pregnant women.  All other forms of prenatal genetic testing requires preauthorization.

2)    Fetal genetic testing can be done in a number of ways. All testing is designed to screen for:

a)    the most common chromosomal anomalies; or

b)    several common congenital problems (spina bifida); or

c)     specific inherited diseases of which the parents are known carriers.

3)    The standard blood testing done early in the second trimester which includes the maternal alpha-fetoprotein test for spina bifida is covered.

4)    Testing for specific inheritable diseases requires pre-authorization (see policies on BI072 Chorionic Villus Sampling and BI017 Amniocentesis.

5)    Four different tests for chromosomal anomalies are covered:

a)    Second trimester (about 16 weeks) amniocentesis; OR

b)    Late first trimester to early second trimester chorionic villus sampling; OR

c)     First trimester triple screening, consisting of ultrasound for fetal nuchal lucency done in conjunction with beta-human chorionic gonadotropin (bHCG) and pregnancy-associated plasma protein A (PAPP-A). All three tests must be done at the same time or none of the three is covered.

d)    Testing of maternal serum for cell free fetal DNA (if a singleton pregnancy and the sample is collected between 9-20 week gestation).

1)    QualChoice will cover fetal genetic testing under certain circumstances:

a)    Amniocentesis is described under the policy on BI017 Amniocentesis.

b)    Chorionic villus sampling (CVS) is described under the policy on BI072 Chorionic Villus Sampling.

c)    The first trimester “triple test” or early second trimester “quadruple test” is covered under certain circumstances:

i)     The parents must receive counseling before the tests are done.

ii)    The parents must be willing to consider pregnancy termination in the case that a sufficient abnormality is detected. See our policy on BI206 Elective Abortion.

iii)   There must be an appropriate indication for the procedure (defined by QualChoice in section 2 below).

iv)   All three tests must be ordered at essentially the same time by the physician performing/interpreting the ultrasound.

2)    The indications for specific fetal genetic testing recognized by QualChoice are:

a)    A history of either mother or father having previously parented a genetically abnormal child.

b)    A family history of an inheritable disease for which there are characteristics that can be defined and detected in cell culture:

i)     This would apply only to CVS or Amniocentesis.

ii)    If the disease is a recessive trait, BOTH parents must have been tested and found to be carriers.

iii)   If the disease is an autosomal dominant trait, EITHER parent must have been tested and found to be a carrier (or a victim) of the disease.

iv)   If the disease is an X-linked trait, then either:

(1)  Father has the disease; OR

(2)  Mother is a carrier.

3)    Cell free fetal DNA screening for aneuploidy is covered in singleton pregnancies when the sample is collected between 9-20 weeks gestation.

4)    Testing for Cri-du-chat and DiGeorge syndrome is not done routinely and therefore requires pre-authorization

5)    Screening for congenital abnormalities with five analytes is considered experimental/investigational and not covered.

Codes Used In This BI:

76813  Ob us nuchal meas 1 gest

76814  Ob us nuchal meas add-on

81599  Unlisted multianalyte assay with algorithmic analysis

81508 Fetal congenital abnormalities, biochemical assays of two proteins

81511 Fetal congenital abnormalities, biochemical assay of 4 analytes (AFP, uE3, hCG, DIA)

84163 PAPP-A serum

84702 Chorionic gonadotropin test

81507 Fetal aneuploidy DNA sequence analysis using maternal serum (chrom 13, 18, 21)

81420 Fetal chrom analysis panel using mat serum (chrom 13, 18, 21)

81422 Fetal chrom microdeletion anal using mat serum (DiGeorge syndr, Cri-du-Chat syndr)

0009M Fetal aneuploidy trisomal risk Deleted code eff 01/01/2020

1)    Gregg AR, Skotko BG, Benkendork MS, et al. Noninvasive prenatal screening for fetal aneuploidy, 2016 update: A position statement of the American College of Genetics and Genomics. Genet Med. published online July 28, 2016. Available at: http://www.nature.com/gim/journal/vaop/ncurrent/pdf/gim201697a.pdf .

2)    ACOG and SMFM Practice Bulletin No. 163, May 2016. Screening for fetal aneuploidy. Obstet Gynecol. 2015 May; 127(5):e123-e137.

3)    ACOG Practice Bulletin No. 162. Prenatal diagnostic testing for genetic disorders. Obstet Gynecol. 2016 May; 127(5):976-978.

Addendum:

1.    Effective 05/01/2017: Clarification for claims processing that only one genetic test for trisomy will be covered (to prevent duplicative testing) with no maternal age restriction or prior authorization required.

2.    Effective 09/01/2019: Quad test coverage added and 81422 with PA.

3.    Effective 10/01/2019: New CPT codes added.

4.    Effective 01/01/2020: Code update – Code 0009M deleted eff 01/01/2020

5.    Effective 07/01/2020: Codes 0124U, 0125U & 0126U deleted

This policy applies to all health plans and products 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) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.