Medical Policy

Effective Date:05/01/2019

Title:Carrier Screening in Pregnancy

Revision Date:

Document:BI617:00

CPT Code(s):81220, 81221, 81222, 81223, 81224, 81401, 81412

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.

This policy outlines medical necessity criteria for cystic fibrosis (CF) and spinal muscular atrophy (SMA) carrier screening as well as carrier screening for members of Ashkenazi Jewish Ancestry (AJA) as recommended by the American College of Medical Genetics (ACMG) and the American College of Obstetricians and Gynecologists (ACOG).

Carrier screening for CF and SMA is recommended for all women early in their pregnancy if they have not previously been tested. Carrier screening for the male partner is usually only needed if the woman has a positive screening test (pre-authorization required). Carrier screening for AJA should be based on a plausible history of Ashkenazi ancestry (pre-authorization required).

Medical Statement

1) Carrier screening should be submitted with diagnosis code Z31.430 for women and Z31.440 for men

2) QualChoice considers CF carrier screening (CPT® code 81220) or SMA carrier screening (81401) medically necessary (without pre-authorization) for women who are pregnant and meet the following criteria:

a) No prior CF or SMA screening results are available, and

b) Pregnancy ≤ 22 weeks gestation, and

c) Underwent pretest counseling.

3) QualChoice considers AJA carrier screening (81412) medically necessary (with pre-authorization) for women who are pregnant and meet the following criteria:

a) A plausible history of Ashkenazi ancestry, and

b) No prior AJA screening results are available, and

c) Pregnancy ≤ 22 weeks gestation, and

d) Underwent pretest counseling.

4) CF, SMA or AJA carrier screening always requires pre-authorization for men (and must meet the following medical necessity criteria):

a) A pregnant spouse with an abnormal carrier screening test, and

b) Pregnancy ≤ 22 weeks gestation, and

c) Underwent pretest counseling.

Codes Used In This BI:

81220	CF gene analysis, ACMG/ACOG screening for common variants
81221	CF known family variants: not ACMG/ACOG screening
81222	CF duplication/deletion variants: not ACMG/ACOG screening
81223	CF full gene sequence: not ACMG/ACOG screening
81224	CF intron 8 poly-T analysis (male infertility): not ACMG/ACOG screening
81401	SMA carrier screening
81412	Ashkenazi Jewish Ancestry panel screening

Limits

1) 81221-81224 are not considered carrier screening and always require pre-authorization regardless of gender or diagnosis.

Reference

1. The American College of Obstetricians and Gynecologists. Carrier screening for genetic conditions. Committee Opinion, Committee on Genetics, No 691, March 2017.

2. Cystic Fibrosis Foundation. CF Genetics. Accessed online at: http://www.cff.org/AboutCF/Testing/Genetics/ .

3. Spinal Muscular Atrophy Foundation. Overview. Accessed online at: http://www.smafoundation.org/about-sma/

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.