O35.04X2 — Maternal care for (suspected) central nervous system malformation or damage in fetus, encephalocele, fetus 2
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Because of the rapid evolution of genetic testing, the decision to rescreen a patient should be undertaken only with the guidance of a genetics professional who can best assess the incremental benefit of repeat testing for additional mutations.
- Carrier screening for a particular condition generally should be performed only once in a person's lifetime and the results should be documented in the patient's health record.
- If an individual is found to be a carrier for a specific condition, the individual's reproductive partner should be offered testing in order to receive informed genetic counseling about potential reproductive outcomes.
- Counseling before screening should include the possibility of results in the 'no-call' category (indeterminate or uninterpretable results).
Key Coverage Criteria
- Preconception or prenatal carrier testing for an individual who has the capacity and intention to reproduce is considered medically necessary when ANY of the following criteria is met:
- There is an identified pathogenic or likely pathogenic variant in a blood relative
- EITHER of the following criteria is met: an individual's reproductive partner is a known carrier of a disease-causing pathogenic or likely pathogenic variant in a recessively inherited condition
- EITHER of the following criteria is met: a genetic diagnosis has been confirmed in an affected relative, AND the affected relative has not had genetic testing and is unavailable for testing
- Preconception or prenatal genetic testing of a prospective parent whose sex assigned at birth is female for Fragile X (i.e., FMR1) pathogenic/likely pathogenic gene variants is considered medically necessary for EITHER of the following indications:
- family history of unexplained intellectual disability or developmental delay, or autism in a blood relative
1 Active Policy
CIGNA-0514 — Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis - (0514)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.