S3870 — Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability
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
- Medical Records Documentation Used for Reviews: Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the guidelines titled Medical Records Documentation Used for Reviews.
- Pre-test genetic counseling is strongly recommended in order to inform persons being tested about the advantages and limitations of the test as applied to a unique person.
- Comprehensive patient pretest and posttest genetic counseling from an obstetrician-gynecologist or other health care provider with genetics expertise regarding the benefits, limitations, and results of chromosomal microarray analysis is essential. CMA should not be ordered without informed consent, which should include discussion of the potential to identify findings of uncertain significance, non-paternity, consanguinity, and adult-onset disease.
Key Coverage Criteria
- Pre-test genetic counseling is strongly recommended in order to inform persons being tested about the advantages and limitations of the test as applied to a unique person.
- Chromosome microarray testing using array comparative genomic hybridization (aCGH) and/or single-nucleotide polymorphism (SNP) array is proven and medically necessary for the following:
- Evaluation of an embryo/fetus in the following cases:
- Intrauterine Fetal Demise or Stillbirth
- Testing the products of conception following pregnancy loss
- Individuals undergoing invasive prenatal testing (i.e., amniocentesis, chorionic villus sampling, or fetal tissue sampling)
5 Active Policies
AMBETTER-CG-Multi-Inher-DO.-Intel-Dis.-DD-2025.1 — Concert Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay
UHC-POL-chromosome-microarray-testing — Chromosome Microarray Testing (Non-Oncology Conditions)
CARELON-chromosomal-microarray-analysis-2025-07-26-updated-2026-01-01 — Chromosomal Microarray Analysis
UMR-POL-UMR-chromosome-microarray-testing — Chromosome Microarray Testing (Non-Oncology Conditions)
Related Codes
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