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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 09/08/2004 Title: Amniocentesis
Revision Date: 07/01/2017 Document: BI017:00
CPT Code(s): 59000, 76946, 88235, 88267, 88269, 88280, 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.

Amniocentesis is covered when it is medically appropriate and necessary for the management of the pregnancy.  Genetic testing of the fetus is covered only in very special circumstances. The most common reasons are because the mother is over the age of 35 or because there is a significantly increased risk for fetal abnormality.

See also the policy on Chorionic Villus Sampling.


Medical Statement

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

Elective amniocentesis 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 amniocentesis and chromosome karyotyping.  Karyotyping is covered only when the results are to be used to affect the management of the pregnancy. 

Amniocentesis and karyotyping will be covered for the following conditions:

  • Mother is 35 years of age or over; OR
  • There is an abnormal maternal serum screen (such as the Quad Screen) with or without an abnormal nuchal translucency; OR
  • Abnormal fetal ultrasound examination reveals signs proven to be associated with fetal genetic abnormalities; OR

Amniocentesis will be covered for the following conditions:

  • There is a need to determine the fetal lung maturity; OR
  • There is a need to determine fetal Rh factor or need to transfuse the fetus for Rh isoimmunization.
  • There is a need to measure amniotic fluid alpha-feto protein (AFP) and/or Acetylcholinesterase (ACHE) because of an elevated maternal serum AFP result in this pregnancy

Amniocentesis with specific genetic testing will be considered, but requires preauthorization for the following:

  • There is family history of genetic defects or disease that can be diagnosed by amniocentesis; OR
  • The parents’ ethnic background and/or family history indicate certain autosomal recessive diseases; OR
  • These parents have had a child with an identified and testable genetic disorder; OR
  • These parents have had a child with physical anomalies and unknown chromosomal status.
  • One of the parents of the pregnancy is a known carrier of a chromosomal abnormality; OR
  • Parents have had a previous child with a chromosomal abnormality; OR
  • 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.
  • There is a need to test the  pregnancy for an infectious disease because:              
    • There are clinical signs and symptoms of a current infection in the mother; OR

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

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

See also the policy on Chorionic Villus Sampling. In order to avoid inaccurate, incomplete, or untimely requests, all prior-authorization requests for genetic tests require the following:

a) The request is submitted by the ordering provider office AND

b) Submitted clinical information from patient medical records such as provider clinic progress notes. Information on lab request forms is not accepted, AND

a)    The request is submitted before testing and not more than 3 business days after the collection of specimen.

 

Codes Used In This BI:

59000

Amniocentesis diagnostic

76946

Echo guide for amniocentesis

88235

Tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells

88267

Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, w/banding

88269

Chromosome analysis, in situ for anatomic fluid cells, count cells from 6 - 12 colonies, 1 karyotype, w/banding

88280

Chromosome analysis; addt`l karyotypes, ea study

88291

Cytogenetics and molecular cytogenetics, interp and report


Limits

Invasive prenatal diagnosis is generally not covered following advanced reproductive technologies (i.e., in vitro fertilization) solely because the member has undergone advanced reproductive technology.  Such indications for testing are considered investigational, are not supported by the American Society of Reproductive Medicine Guidelines, and are not covered.


Reference

Addendum:

 

1.     Effective 07/01/2017: Clarified requirements for genetic testing pre-authorization requests including submission has to be by the ordering provider within 3 business days of collection of specimen. Clinical on lab forms are not acceptable.

 


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.
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