84704
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation of prior or concurrent microarray or NIPT/maternal cell-free DNA testing (to support limitation/exclusion when such testing already performed).
- Evidence that NT measurements were performed in a setting with demonstrated ultrasound credentialing and ongoing quality monitoring (e.g., participation in NT credentialing programs such as NTQR or FMF-US).
- Documentation of gestational age at time of testing (tests and NT measurements should be performed in the appropriate first-trimester window; the policy references 11–13 weeks gestation for combined first-trimester screening and notes NT measurement windows [e.g., 10–14 weeks or 11 weeks +1 day to 13 weeks +6 days in cited trials]).
- Record of the type and results of serum analyte tests performed (PAPP-A and hCG [free beta, total, or hyperglycosylated forms]; and, if applicable, second-trimester analytes: MSAFP, unconjugated estriol, inhibin A, hCG).
Key Coverage Criteria
- ICD-10 codes covered if selection criteria are met: Q90.0 - Q99.9 (Chromosomal anomalies) and Z36.0 - Z36.4, Z36.82, Z36.89 - Z36.9, Z36.8A (Encounter for antenatal screening of mother).
- Services coded to the listed CPT/HCPCS/ICD-10 codes when selection criteria (as described above and in the policy) are met. (Covered CPT codes include, when selection criteria met: 76813, 76814, 81509, 81510, 81511, 81512, 84704; covered ICD-10 codes include Q90.0–Q99.9 and Z36.0–Z36.4, Z36.82, Z36.89–Z36.9, Z36.8A.)
- First-trimester nuchal translucency (NT) testing alone (without serum analyte screening) for multiple gestations.
- First-trimester NT measurement combined with first-trimester serum analyte tests that include pregnancy-associated plasma protein A (PAPP-A) plus beta-human chorionic gonadotropin (hCG) (free beta hCG, total hCG, or hyperglycosylated hCG are considered interchangeable).
- Integrated, sequential, or contingent screening that includes first-trimester triple test (NT, PAPP-A, and hCG) plus second-trimester quadruple test (maternal serum alpha-fetoprotein [MSAFP], unconjugated estriol [uE3], inhibin A, and hCG).
- Second-trimester serum analyte screening (per CPB 0464 - Serum and Urine Marker Screening for Fetal Aneuploidy).
4 Active Policies
AETNA-CPB-0464 — Serum and Urine Marker Screening for Fetal Aneuploidy
AETNA-CPB-0282 — Noninvasive Down Syndrome Screening
AETNA-CPB-0352 — Tumor Markers
ANTHEM-LAB.00040 — LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia
Related Codes
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