0396U
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Record of genetic counseling performed by a qualified provider (genetic counselor, medical geneticist, or advanced practice practitioner specializing in genetics).
- Documentation that patients undergoing PGT-M or PGT-SR were offered diagnostic confirmation (CVS or amniocentesis).
- Documentation that patients undergoing PGT-A were offered traditional diagnostic testing or aneuploidy screening consistent with pregnancy screening guidelines.
- Documentation that an experienced genetic counselor was involved in the decision process.
Key Coverage Criteria
- PGT-M (preimplantation genetic testing for monogenic disorders) for couples at increased risk of transmitting a known gene mutation when testing can target the specific mutation; performed in conjunction with IVF to prevent birth of affected children.
- PGT-SR (preimplantation genetic testing for structural rearrangements) for couples at increased risk of transmitting an unbalanced structural chromosomal rearrangement when testing can target the rearrangement; performed in conjunction with IVF to prevent birth of affected children.
- PGT-A (preimplantation genetic testing for aneuploidy) as untargeted screening for potential chromosomal or subchromosomal abnormalities in conjunction with IVF.
- Genetic counseling is recommended for patients considering or undergoing in vitro fertilization.
- Patients undergoing PGT-M or PGT-SR should be offered diagnostic confirmation testing via chorionic villus sampling (CVS) or amniocentesis.
- Preimplantation genetic testing—monogenic (PGT‑M) has established clinical utility for identifying embryos at risk for single‑gene disorders.
1 Active Policy
AMBETTER-CG-Preimplantation-Testing-2025.1 — Concert Genetic Testing: Preimplantation Genetic Testing
Related Codes
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