84702
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- When relevant to interpretation of no-call results: documentation of fetal fraction/genomic equivalents and relevant maternal factors (e.g., maternal weight) and sample handling/transport records (sample compromise was cited as affecting results).
- Documentation of receipt (or non-receipt) of a second maternal blood sample when one is requested following an initial no call.
- Newborn outcomes obtained from parent survey responses or provider reports (used in study outcome ascertainment).
- Molecular testing results when available for affected cases (study noted molecular testing completed for affected CF and SMA cases either as part of NBS or clinical indication).
Key Coverage Criteria
- Coverage of the above CPT codes is conditional: “CPT codes covered if selection criteria are met.”
- Alpha-fetoprotein (AFP); amniotic fluid (CPT 82106)
- Estriol (CPT 82677)
- Gonadotropin, chorionic (hCG); quantitative (CPT 84702)
- Gonadotropin, chorionic (hCG); qualitative (CPT 84703)
- Gonadotropin, chorionic (hCG) free beta chain (CPT 84704)
3 Active Policies
AMBETTER-CP.MP.130 — Fertility Preservation
AETNA-CPB-0464 — Serum and Urine Marker Screening for Fetal Aneuploidy
ANTHEM-CG-LAB-27 — CG-LAB-27 Human Chorionic Gonadotropin Testing
Related Codes
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