96040
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documented clinical indication meeting one of the medical necessity criteria listed (e.g., consanguinity, familial cancer disorder, ethnic risk, known parental chromosomal abnormality, infertility with parental chromosomal abnormality, primary amenorrhea/azospermia/abnormal sexual development, maternal carrier status for X-linked disorder, parental carrier status for autosomal recessive disorder, parent of child with genetic disorder or developmental disability, abnormal prenatal screening/ultrasound/AFP/sickle cell test, maternal age ≥35 at delivery, exposure to teratogenic/mutagenic/carcinogenic agents, prior unexplained stillbirth or recurrent first trimester miscarriages, contemplating pregnancy with an autosomal dominant disorder in a parent).
- Results of relevant tests when applicable: prenatal ultrasound findings, multiple marker screening results, maternal serum AFP test, sickle cell testing, chromosome analysis or other genetic test results, carrier testing results.
- For infertility-related counseling: documentation that either parent is known to have a chromosomal abnormality or relevant infertility diagnosis/testing (e.g., azoospermia, male or female infertility ICD codes).
Key Coverage Criteria
- Aetna considers genetic counseling in connection with pregnancy management medically necessary for evaluation of any of the following:
- Couples who are closely related genetically (consanguinity, incest)
- Familial cancer disorders
- Individuals from ethnic groups recognized to be at increased risk for specific genetic disorders (e.g., African Americans for sickle cell anemia, Ashkenazi [eastern European] Jews for Tay-Sachs disease)
- Infertility cases where either parent is known to have a chromosomal abnormality
- Individuals with primary amenorrhea, azospermia, abnormal sexual development or failure in developing secondary sexual characteristics
3 Active Policies
AETNA-CPB-0189 — Genetic Counseling
AETNA-CPB-0323 — Preconceptional Sex Selection Techniques
AETNA-CPB-0327 — Infertility
Related Codes
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