88261
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
- Clinical documentation confirming type of pregnancy loss (miscarriage, IUFD, stillbirth) and medical indication for genetic testing.
- Documentation of specimen source and availability (POC, amniotic fluid, CVS, PUBS) and confirmation that fresh tissue was submitted when applicable.
- Laboratory reports including method used (e.g., cell culture and karyotyping) and results or reason for non-diagnostic testing (e.g., culture failure, maternal cell contamination).
- Documentation of genetic counseling (notes summarizing counseling and facilitation of decision making) is strongly recommended and should be included in the medical record.
Key Coverage Criteria
- Prenatal diagnostic evaluation for suspected Noonan spectrum disorders / RASopathies (as referenced).
- Prenatal diagnostic testing to identify genetic conditions in fetuses at increased risk based on abnormal prenatal screening results.
- Prenatal diagnostic testing for women who elect diagnostic testing due to other risk factors (e.g., abnormal ultrasound findings).
- Prenatal diagnostic testing for women with a history of a previous pregnancy affected by aneuploidy.
- Genetic testing to determine the cause of isolated or recurrent pregnancy loss, including miscarriage, intrauterine fetal demise (IUFD), and stillbirth.
- Genetic analysis of products of conception (POC) — typically by cell culture and karyotyping — when fresh tissue is available.
1 Active Policy
AMBETTER-CG-Prenatl-Diag-via-Amn-etc.-Preg-Loss-2025.1 — Concert Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss
Related Codes
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