86828
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
- Documentation (and counseling) that traditional diagnostic testing or screening for aneuploidy should be offered to all patients who have had PGT-A: "Traditional diagnostic testing or screening for aneuploidy should be offered to all patients who have had PGT-A..." (ACOG 2020).
- Evidence of informed consent and counseling regarding limitations, accuracy, and need for confirmatory invasive testing for chromosomal abnormalities (explicit in ACOG, ASRM and other society statements in the document).
- When PCR-based single-cell testing is performed, use of ICSI is recommended to avoid contamination; documentation of insemination method may be required where PCR-based PGT-M is used: "for carriers of single gene disorders where PCR will be applied... ICSI is recommended to avoid cellular DNA from non-fertilizing sperm." (PGDIS / ESHRE guidance cited).
Key Coverage Criteria
- PGT-M / PGD is medically necessary when the genetic disease is associated with clinically significant morbidity or disability.
- Invasive prenatal diagnosis by chorionic villus sampling (CVS), genetic amniocentesis, and percutaneous umbilical blood sampling (PUBS / cordocentesis) for diagnosis of fetal chromosomal abnormalities.
- Preimplantation genetic testing for monogenic disorders (PGT-M / formerly PGD) on single cells is medically necessary when ALL of the PGT-M criteria in this policy are met (see below).
- PGT-M / PGD is medically necessary to diagnose an autosomal dominant condition when at least one parent is a known carrier.
- PGT-M / PGD is medically necessary to diagnose an autosomal recessive condition when both parents are known carriers (example: cystic fibrosis when parents are known mutation carriers).
- PGT-M / PGD is medically necessary to diagnose an X-linked condition when at least one parent is a known carrier (example: hemophilia).
20 Active Policies
BCBSIL-SUR703.029 — Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
BCBSMT-SUR703.029 — Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
BCBSNM-SUR703.029 — Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
BCBSOK-SUR703.029 — Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.