Aetna Invasive Prenatal Diagnosis of Genetic Diseases coverage criteria

What this means for the claim

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Coverage criteria

• Invasive prenatal diagnosis by chorionic villus sampling (CVS), genetic amniocentesis, and percutaneous umbilical blood sampling (PUBS) (cordocentesis) is considered medically necessary for diagnosis of fetal chromosomal abnormalities.
• Preimplantation genetic testing for monogenic disorders (PGT-M / PGD) is considered medically necessary when ALL of the following criteria are met: (a) technical and clinical performance of the genetic test is supported by published peer-reviewed medical literature; AND (b) PGT-M / PGD is performed for ONE of the following indications: to diagnose an autosomal dominant condition when at least one parent is a known carrier, OR to diagnose an autosomal recessive condition when both parents are known carriers, OR to diagnose an X-linked condition when at least one parent is a known carrier; AND (c) results of genetic testing will directly impact and change management; AND (d) the PGT-M / PGD procedure will eliminate the need for subsequent invasive prenatal diagnosis; AND (e) a specific mutation, or set of mutations, has been identified that specifically identifies the genetic disease; AND (f) the genetic disease is associated with clinically significant morbidity or disability.
• Preimplantation genetic testing for structural rearrangements (PGT-SR) is considered medically necessary for pregnancies in which one of the reproductive partners is known to carry a balanced translocation or inversion.
• Conventional cytogenetic analysis and quantitative fluorescent polymerase chain reaction (QF-PCR) are considered medically necessary methods to detect trisomies whenever prenatal testing is performed solely because of an increased risk of aneuploidy in chromosomes 13, 18, 21, X or Y.
• Both conventional cytogenetics AND QF-PCR are considered medically necessary in ALL cases of prenatal diagnosis referred for a fetal ultrasound abnormality (including an increased nuchal translucency measurement greater than 3.5 mm) OR a familial chromosomal rearrangement.
• Cytogenetic follow-up of QF-PCR findings of trisomy 13 and 21 is considered medically necessary to rule out inherited Robertsonian translocations.
• For members with ART (assisted reproductive technology) benefits who meet PGT-M criteria but do NOT meet medical necessity criteria for in vitro fertilization (IVF): intracytoplasmic sperm injection (ICSI) for creation of the embryos to avoid contamination from non-fertilizing sperm, and the embryo biopsy procedure and testing of the biopsied material, are considered medically necessary.
• For members with ART benefits who meet BOTH PGT-M criteria AND medical necessity criteria for IVF: intracytoplasmic sperm injection (ICSI) for creation of the embryos to avoid contamination from non-fertilizing sperm, and the embryo biopsy procedure and testing of the biopsied material, are considered medically necessary; other IVF-related procedures are considered medically necessary subject to CPB 0327 - Infertility criteria and applicable plan limits.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 89290·PA verdict·Rate
• 89291·PA verdict·Rate

Frequently asked questions

When does Aetna cover Invasive Prenatal Diagnosis of Genetic Diseases (CPT 89290), and what gets it denied?

Aetna covers invasive prenatal diagnosis of fetal chromosomal abnormalities (CVS, genetic amniocentesis, and PUBS/cordocentesis), along with conventional cytogenetics and QF-PCR for aneuploidy risk, fetal ultrasound abnormalities, or familial rearrangements. Preimplantation genetic testing for monogenic disorders (PGT-M/PGD) is covered only when all listed criteria are met (including a known parental carrier for the specific mutation and an indication that is autosomal dominant, autosomal recessive, or X-linked), and PGT-SR is covered when a partner carries a balanced translocation or inversion; PGT-A, PGT-M for sex selection, multigene panels at PGT-M, testing for variants of uncertain significance, HLA-matching PGT, and several named commercial PGT tests are not covered (experimental/investigational or not medically necessary). The bulletin is silent on precertification. Coverage criteria include: Invasive prenatal diagnosis by chorionic villus sampling (CVS), genetic amniocentesis, and percutaneous umbilical blood sampling (PUBS) (cordocentesis) is considered medically necessary for diagnosis of fetal chromosomal abnormalities.; Preimplantation genetic testing for monogenic disorders (PGT-M / PGD) is considered medically necessary when ALL of the following criteria are met: (a) technical and clinical performance of the genetic test is supported by published peer-reviewed medical literature; AND (b) PGT-M / PGD is performed for ONE of the following indications: to diagnose an autosomal dominant condition when at least one parent is a known carrier, OR to diagnose an autosomal recessive condition when both parents are known carriers, OR to diagnose an X-linked condition when at least one parent is a known carrier; AND (c) results of genetic testing will directly impact and change management; AND (d) the PGT-M / PGD procedure will eliminate the need for subsequent invasive prenatal diagnosis; AND (e) a specific mutation, or set of mutations, has been identified that specifically identifies the genetic disease; AND (f) the genetic disease is associated with clinically significant morbidity or disability.; Preimplantation genetic testing for structural rearrangements (PGT-SR) is considered medically necessary for pregnancies in which one of the reproductive partners is known to carry a balanced translocation or inversion.; Conventional cytogenetic analysis and quantitative fluorescent polymerase chain reaction (QF-PCR) are considered medically necessary methods to detect trisomies whenever prenatal testing is performed solely because of an increased risk of aneuploidy in chromosomes 13, 18, 21, X or Y.; Both conventional cytogenetics AND QF-PCR are considered medically necessary in ALL cases of prenatal diagnosis referred for a fetal ultrasound abnormality (including an increased nuchal translucency measurement greater than 3.5 mm) OR a familial chromosomal rearrangement.; Cytogenetic follow-up of QF-PCR findings of trisomy 13 and 21 is considered medically necessary to rule out inherited Robertsonian translocations.; For members with ART (assisted reproductive technology) benefits who meet PGT-M criteria but do NOT meet medical necessity criteria for in vitro fertilization (IVF): intracytoplasmic sperm injection (ICSI) for creation of the embryos to avoid contamination from non-fertilizing sperm, and the embryo biopsy procedure and testing of the biopsied material, are considered medically necessary.; For members with ART benefits who meet BOTH PGT-M criteria AND medical necessity criteria for IVF: intracytoplasmic sperm injection (ICSI) for creation of the embryos to avoid contamination from non-fertilizing sperm, and the embryo biopsy procedure and testing of the biopsied material, are considered medically necessary; other IVF-related procedures are considered medically necessary subject to CPB 0327 - Infertility criteria and applicable plan limits.. Applies to 2 codes: 89290, 89291. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Intracytoplasmic sperm injection (ICSI) for the creation of the embryos is considered NOT medically necessary for PGT-A (preimplantation genetic testing for aneuploidy, formerly called preimplantation genetic screening [PGS]).; PGT-M (formerly called PGD) is considered NOT medically necessary for sex selection for non-medical purposes.; Invasive prenatal screening and preimplantation genetic testing for a VUS (also known as unclassified variant or variant of uncertain significance) is considered experimental, investigational, or unproven.; Multigene panels at time of PGT-M / PGD testing are considered experimental, investigational, or unproven.; PGT-A (preimplantation genetic testing for aneuploidy; formerly called preimplantation genetic screening [PGS]) (detecting either too many or too few chromosomes in an embryo), including but not limited to optimization of IVF outcomes, history of failed IVF cycles, or recurrent miscarriages, is considered experimental, investigational, or unproven.; PGT-M / PGD for fetal chromosomal abnormalities is considered experimental, investigational, or unproven because the procedure is not as accurate as cytogenetic analysis performed on prenatal diagnosis specimens obtained by chorionic villus sampling (CVS) or amniocentesis.; PGT-M / PGD to determine the human leukocyte antigen (HLA) or other marker status of an embryo as a potential donor for future stem cell transplant is considered experimental, investigational, or unproven because PGT-M / PGD has not been established as the standard of care for assessing the suitability of embryos for stem cell transplantation.; Igenomix PGT-M (Preimplantation Genetic Testing for Monogenic Disorders) test is considered experimental, investigational, or unproven due to insufficient evidence of technical and clinical performance in published peer-reviewed medical literature.; Igenomix PGT-SR and Smart PGT-SR Plus (Preimplantation Genetic Testing for Chromosomal Structural Rearrangements) tests are considered experimental, investigational, or unproven due to insufficient evidence of technical and clinical performance in published peer-reviewed medical literature.; Igenomix Smart PGT-A and Smart PGT-A Plus (Preimplantation Genetic Testing - Aneuploidy) tests are considered experimental, investigational, or unproven due to insufficient evidence of technical and clinical performance in published peer-reviewed medical literature.; IriSight Prenatal Analysis is considered experimental, investigational, or unproven due to insufficient evidence of technical and clinical performance in published peer-reviewed medical literature.; Natera Spectrum PGT-M (preimplantation genetic testing for monogenic disorders) is considered experimental, investigational, or unproven due to insufficient evidence of technical and clinical performance in published peer-reviewed medical literature. Claims may be denied when the requested service falls under these.

Does Aetna require prior authorization for Invasive Prenatal Diagnosis of Genetic Diseases?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.

What does Aetna exclude for Invasive Prenatal Diagnosis of Genetic Diseases?

Policy exclusions and limitations: Intracytoplasmic sperm injection (ICSI) for the creation of the embryos is considered NOT medically necessary for PGT-A (preimplantation genetic testing for aneuploidy, formerly called preimplantation genetic screening [PGS]).; PGT-M (formerly called PGD) is considered NOT medically necessary for sex selection for non-medical purposes.; Invasive prenatal screening and preimplantation genetic testing for a VUS (also known as unclassified variant or variant of uncertain significance) is considered experimental, investigational, or unproven.; Multigene panels at time of PGT-M / PGD testing are considered experimental, investigational, or unproven.; PGT-A (preimplantation genetic testing for aneuploidy; formerly called preimplantation genetic screening [PGS]) (detecting either too many or too few chromosomes in an embryo), including but not limited to optimization of IVF outcomes, history of failed IVF cycles, or recurrent miscarriages, is considered experimental, investigational, or unproven.; PGT-M / PGD for fetal chromosomal abnormalities is considered experimental, investigational, or unproven because the procedure is not as accurate as cytogenetic analysis performed on prenatal diagnosis specimens obtained by chorionic villus sampling (CVS) or amniocentesis.; PGT-M / PGD to determine the human leukocyte antigen (HLA) or other marker status of an embryo as a potential donor for future stem cell transplant is considered experimental, investigational, or unproven because PGT-M / PGD has not been established as the standard of care for assessing the suitability of embryos for stem cell transplantation.; Igenomix PGT-M (Preimplantation Genetic Testing for Monogenic Disorders) test is considered experimental, investigational, or unproven due to insufficient evidence of technical and clinical performance in published peer-reviewed medical literature.; Igenomix PGT-SR and Smart PGT-SR Plus (Preimplantation Genetic Testing for Chromosomal Structural Rearrangements) tests are considered experimental, investigational, or unproven due to insufficient evidence of technical and clinical performance in published peer-reviewed medical literature.; Igenomix Smart PGT-A and Smart PGT-A Plus (Preimplantation Genetic Testing - Aneuploidy) tests are considered experimental, investigational, or unproven due to insufficient evidence of technical and clinical performance in published peer-reviewed medical literature.; IriSight Prenatal Analysis is considered experimental, investigational, or unproven due to insufficient evidence of technical and clinical performance in published peer-reviewed medical literature.; Natera Spectrum PGT-M (preimplantation genetic testing for monogenic disorders) is considered experimental, investigational, or unproven due to insufficient evidence of technical and clinical performance in published peer-reviewed medical literature. Claims may be denied when the requested service falls under these.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT