S4016 — Frozen in vitro fertilization cycle, case rate
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
- Physician order for PGT documented after genetic counseling (PGT must be ordered by a physician after genetic counseling).
- Documentation of genetic counseling session and that counseling occurred prior to ordering PGT.
- Clinical documentation that the genetic medical condition, if passed onto offspring, would result in Significant Health Problems or Severe Disability and is caused by a single gene (for PGT-M) or structural changes of a parent's chromosome (for PGT-SR).
- Documentation of parental genetic status demonstrating reason for increased embryonic risk (e.g., both intended parents are carriers of the same autosomal recessive disease; at least one parent carrier of an autosomal dominant, sex-linked, or mitochondrial condition; or at least one parent carrier of a structural chromosome rearrangement).
Key Coverage Criteria
- Preimplantation Genetic Testing (PGT) for monogenic/single gene defects (PGT-M) or inherited structural chromosome rearrangements (PGT-SR) is proven and medically necessary using polymerase chain reaction (PCR), next generation sequencing (NGS) (e.g., chromosomal rearrangements), or chromosomal microarray (CMA) when the embryo is at increased risk of a recognized inherited disorder.
- The increased risk of a recognized inherited disorder is due to one of the following: each of the intended parents are carriers of the same autosomal recessive disease.
- The increased risk of a recognized inherited disorder is due to at least one parent being a carrier of an autosomal dominant, sex-linked, or mitochondrial condition.
- The increased risk of a recognized inherited disorder is due to at least one parent being a carrier of a structural chromosome rearrangement.
- The medical condition being prevented must result in Significant Health Problems or Severe Disability and be caused by a single gene (PGT-M) or structural changes of a parent's chromosome (PGT-SR).
- PGT is proven and medically necessary for human leukocyte antigen (HLA) typing on an embryo in order for the future child to provide bone marrow or blood to treat an affected sibling.
4 Active Policies
AMBETTER-CP.MP.55 — Assisted Reproductive Technology
UHC-POL-preimplantation-genetic-testing — Preimplantation Genetic Testing and Related Services
UMR-POL-UMR-preimplantation-genetic-testing — Preimplantation Genetic Testing and Related Services
SUREST-POL-SUREST-preimplantation-genetic-testing — Preimplantation Genetic Testing and Related Services
Related Codes
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