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    v1.0.30
    OpenPayerPolicy UpdatesReproductive Health & FertilityArizona Complete Health PGT Coverage Policy Update…
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    CurrentArizona Complete HealthPolicy N/A

    Preimplantation Genetic Testing (PGT) Coverage Criteria

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    Criteria and coding guidance for preimplantation genetic testing (PGT-A, PGT-M, PGT-SR) used with in vitro fertilization; applies to health plans affiliated with Centene Corporation as adopted by Arizona Complete Health.

    Policy Summary
    PayerArizona Complete Health
    PolicyPreimplantation Genetic Testing (PGT) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Last ReviewNov 25, 2024
    Next Review DateN/A
    Key ActionDocument genetic counseling and offer diagnostic confirmation testing when indicated; follow the member's coverage documents for authorization requirements.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3PGT types covered (PGT-A, PGT-M, PGT-SR)
    multipleExample billing codes shown
    4Reference citations
    encouragedGenetic counseling

    Coverage Criteria for Preimplantation Genetic Testing (PGT)

    PGT Coverage Criteria

    Covered when criteria below are met for each PGT type:

    PGT-A stance: Current evidence does not support preimplantation genetic testing for aneuploidy (PGT-A) for all indications.

    Professional societies state insufficient evidence for routine use in all IVF patients.

    PGT-M criteria: PGT-M may be considered medically necessary when the embryo is at an elevated risk of a genetic disorder due to one of the following: (1) both biological parents are known carriers for the same autosomal recessive disorder; OR (2) one biological parent is a known carrier of an autosomal dominant disorder; OR (3) one biological parent is a known carrier of an X-linked recessive disorder.

    Current evidence does not support PGT-M for other indications.

    PGT-SR criteria: PGT-SR may be considered medically necessary when the embryo is at an elevated risk because one biological parent has a chromosomal rearrangement.

    Current evidence does not support PGT-SR for other indications.

    Use of PGT-A, PGT-M, or PGT-SR is not supported for indications other than those specified in this policy. For example, routine use of PGT-A for all IVF patients is not supported. Coverage is limited to the specific medically necessary indications described elsewhere in this policy.

    Where there is a conflict between this clinical policy and state Medicaid coverage provisions, the state Medicaid manual takes precedence. Providers should consult the applicable state Medicaid manual for specific coverage requirements and follow those provisions where they differ from this policy.

    The current evidence base does not support the use of PGT-A, PGT-M, or PGT-SR for indications beyond those listed as medically necessary in this policy. Each PGT type is limited to the circumstances identified in the coverage criteria; other uses are considered not supported by available evidence.

    Example and Referenced Billing Codes

    Example/Referenced Codes for PGT-A, PGT-M, PGT-SRmixed
    81229Referenced for PGT-A/PGT-SR (document)
    81479Unlisted molecular pathology procedure (referenced)
    89290Embryo biopsy (referenced)
    89291Embryo transfer/handling (referenced)
    0254UPLA example for SMART PGT-A (Igenomix) referenced
    0396UPLA example for PGT-M (CooperGenomics) referenced
    N97.0Documented diagnosis code referenced
    N97.9Documented diagnosis code referenced
    Z31Encounter for procreative management (referenced)
    Z14.8Genetic carrier status code referenced

    Provider Actions, Prior Authorization and Documentation

    Billing Rule

    Billing codes referenced (informational)

    Codes referenced in this policy are provided for informational purposes only. Inclusion or exclusion of a code does not guarantee coverage. Providers should verify current coding guidance and payer-specific billing requirements prior to claim submission.

    • Examples of commonly referenced codes: 81228, 81229, 81479, 0396U, 0254U, 89290, 89291, diagnosis codes N97.0, N97.9, Z14.8, Z31 (informational)
    Prior Authorization

    Prior authorization guidance

    Prior authorization requirements vary by Health Plan. This policy is intended as a guide; the need for prior authorization and the specific requirements (including documentation and authorization submission procedures) are determined by the member’s Health Plan. Providers must obtain any required prior authorization before providing services when applicable.

    • Prior authorization is not implied by this policy — check the member's coverage document and plan-specific authorization policies.
    • When prior authorization is required, submit clinical documentation supporting medical necessity as specified by the Health Plan.
    Documentation Required

    Genetic counseling and documentation

    Genetic counseling is highly encouraged for patients considering and undergoing IVF. When genetic testing is ordered, document that genetic counseling was offered or provided. Offer confirmatory diagnostic testing when appropriate based on PGT results and clinical context.

    • Document the counseling encounter, including risks/benefits discussed and patient decision.
    • If a PGT result indicates a genetic abnormality, ensure follow-up counseling and offer diagnostic confirmation.
    Note

    Coverage document adherence

    Coverage determinations and authorizations are subject to the terms, conditions, exclusions, and limitations of the member’s coverage documents. This clinical policy does not guarantee coverage or payment. Providers must follow the member’s evidence of coverage, certificate of coverage, policy, or contract when seeking authorization or benefits.

    • If plan benefits conflict with this policy, the plan’s coverage document governs.
    • Check plan-level edits and contractual limitations prior to scheduling services.

    Background on Preimplantation Genetic Testing

    Preimplantation genetic testing (PGT) refers to genetic analysis of biopsied embryonic cells obtained during in vitro fertilization (IVF) to evaluate embryos prior to transfer. PGT-A screens for chromosomal aneuploidy, PGT-M detects specific single-gene inherited disorders, and PGT-SR assesses structural chromosomal rearrangements. These tests are used selectively in IVF when embryos are at elevated risk for the targeted genetic condition; professional society guidance supports established utility for certain indications while evidence is insufficient to support routine use of PGT-A in all IVF patients.

    Definitions and PGT Type Descriptions

    PGT-A — definition and key points
    DefinitionPreimplantation genetic testing for aneuploidy (PGT-A) is used to screen for chromosomal aneuploidy in conjunction with in vitro fertilization (IVF).
    Typical use settingPerformed on biopsied embryonic cells during an IVF cycle to assess chromosomal number abnormalities before embryo transfer.
    Coverage stance summaryCurrent evidence does not support routine use of PGT-A for all IVF patients; medical necessity limited to indications specified in the policy.
    Related provider actionGenetic counseling is highly encouraged prior to testing and results should be confirmed with diagnostic testing when indicated.
    PGT-M — definition and coverage highlights
    DefinitionPreimplantation genetic testing for monogenic disorders (PGT-M) is used to detect a specific single-gene inherited disorder or chromosome rearrangement in conjunction with in vitro fertilization (IVF).
    Medical necessity criteriaMay be considered medically necessary when the embryo is at elevated risk due to parental carrier status for the same autosomal recessive disorder, an autosomal dominant disorder in one parent, or an X-linked recessive disorder in one parent.
    LimitationsPGT-M is not supported for indications beyond those specified in the policy.
    Related provider actionDocument parental carrier status and provide genetic counseling as part of authorization and care planning.
    PGT-SR — definition and coverage highlights
    DefinitionPreimplantation genetic testing for structural rearrangements (PGT-SR) is used to detect structural chromosome rearrangements in conjunction with in vitro fertilization (IVF).
    Medical necessity criteriaMay be considered medically necessary when the embryo is at elevated risk because one biological parent has a chromosomal rearrangement.
    LimitationsPGT-SR is not supported for indications beyond those specified in the policy.
    Related provider actionInclude documentation of parental chromosomal rearrangement and consider genetic counseling prior to testing.
    Preimplantation genetic testing (PGT) — professional guidance
    DefinitionPreimplantation genetic testing (PGT) refers collectively to PGT-A, PGT-M, and PGT-SR and is referenced through professional society guidance documents addressing use, limitations, mosaic results, and adult-onset conditions.
    Key referencesASRM and ACOG committee opinions and practice committee statements guide appropriate use and limitations of PGT (see referenced society documents).
    Clinical implicationProfessional societies acknowledge established utility for PGT-M and PGT-SR; evidence is insufficient for routine PGT-A in all IVF patients.
    Recommended provider practiceGenetic counseling by experienced genetics professionals is highly encouraged and management of mosaic results should follow professional society guidance.
    Policy Summary
    PayerArizona Complete Health
    PolicyPreimplantation Genetic Testing (PGT) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Last ReviewNov 25, 2024
    Next Review DateN/A
    Key ActionDocument genetic counseling and offer diagnostic confirmation testing when indicated; follow the member's coverage documents for authorization requirements.
    SourceLink
    On This Page
    Coverage Criteria for Preimplantation Genetic Testing (PGT)Example and Referenced Billing CodesProvider Actions, Prior Authorization and DocumentationBackground on Preimplantation Genetic TestingDefinitions and PGT Type Descriptions

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