CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO22

Prenatal Screening for Fetal Aneuploidy

Defines Blue Cross Blue Shield New Mexico's reimbursement and coverage criteria for prenatal screening tests to detect fetal aneuploidy and related confirmatory testing; applies to providers ordering or billing these tests for BCBSNM members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrenatal Screening for Fetal Aneuploidy

Policy CodePolicy CPCPLABO22

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionOffer confirmatory diagnostic testing (CVS or amniocentesis) for positive or equivocal screening results and confirm reimbursement eligibility with plan documents.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

01/01/2023plan effective date

8codes referenced

5 bulletsreimbursement rules

Coverage Criteria — Prenatal Screening

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Confirmatory testing of equivocal and positive results via Chorionic Villus Sampling (CVS) or Amniocentesis should be offered and may be reimbursable for women wishing to pursue additional testing

clinical follow-up for positive/equivocal screens

Alpha‑fetoprotein screening: Alpha-fetoprotein (AFP) screening for pregnant women between 16 and 20 weeks of pregnancy may be reimbursable when not performed as part of a 'penta' screengestational age 16-20 weeks

single AFP screen permitted if not within penta panel

Explicit non-reimbursable conditions (see exclusions) — not covered: The use of the 'penta' screen (hCG, AFP, UE3, DIA with nuchal translucency, and hyperglycosylated hCG) is not reimbursable; parallel or simultaneous testing with multiple screening methodologies for fetal aneuploidy is not reimbursable; screening of multiple-gestation pregnancies with tests other than nuchal translucency and/or subsequent diagnostic testing via CVS or amniocentesis is not reimbursable; egg donor pregnancies are excluded; repeat screening after negative results is excluded; screening for determination of fetal sex is excluded

These conditions are expressly listed as not reimbursable under this policy

Claims for the use of the "penta" screen — defined in this policy as the multi‑marker panel including hCG, AFP, UE3, DIA with nuchal translucency (NT), and hyperglycosylated hCG — are not reimbursable. Additionally, parallel or simultaneous testing with multiple screening methodologies to detect fetal aneuploidy is not reimbursable. Providers should not bill for combinations of screening methods performed at the same time when those methods represent overlapping approaches to aneuploidy detection.

Use of the penta screen is explicitly excluded from reimbursement under this policy. Parallel or simultaneous multiple‑method screening for fetal aneuploidy is likewise excluded. For multiple gestation pregnancies, only nuchal translucency (NT) measurement and subsequent diagnostic testing via chorionic villus sampling (CVS) or amniocentesis are allowable; other screening tests in multiple gestations are not reimbursable because of the increased risk of false positive results. The policy also lists additional nonreimbursable indications including screening in egg‑donor pregnancies, repeat screening after a negative result, and screening performed solely for determination of fetal sex.

Provider Actions, Documentation & Denial Risks

Prior Authorization

Product-specific reimbursement & confirmatory testing

BCBSNM has implemented product-specific lab management reimbursement criteria. Not all requirements apply to every product or plan; providers must review the member's plan documents and provider contract to confirm coverage and reimbursement rules for the specific product.

Confirmatory diagnostic testing (e.g., Chorionic Villus Sampling [CVS] or Amniocentesis) for equivocal or positive screening results should be offered and may be reimbursable when clinically indicated and consistent with the member's plan benefits.
Alpha-fetoprotein (AFP) screening for pregnant women between 16 and 20 weeks may be reimbursable when performed as a standalone AFP test and not as part of a combined 'penta' screen.

Denial Risk

Denial triggers for specific screening methods

Certain screening methods and testing combinations are denial triggers. Claims for these methods are not reimbursable and will be denied if submitted.

Use of the 'penta' screen (hCG, AFP, UE3, DIA with NT, and hyperglycosylated hCG) to detect fetal aneuploidy is not reimbursable.
Parallel or simultaneous testing with multiple screening methodologies for fetal aneuploidy is not reimbursable.
Screening of women with multiple gestation pregnancies using any testing other than nuchal translucency and/or diagnostic testing via CVS or Amniocentesis is not reimbursable due to high false positive risk.

Documentation Required

Documentation, coding expectations & denial risks

Providers are responsible for submission of accurate documentation and appropriate coding for services rendered. BCBSNM may request additional documentation to adjudicate claims; failure to supply requested documentation can result in claim denial or delay.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.) and follow industry coding guidelines and plan-specific billing rules.
Upon request, provide supporting clinical documentation for confirmatory testing decisions, indications for screening, and rationale when screening falls into higher-risk categories (e.g., multiple gestation, egg-donor pregnancies).
Review member plan documents to determine whether specific tests (including repeat screening after a negative result and fetal sex determination testing) are excluded for that member.
Repeat screening after a negative result, screening for determination of fetal sex, and screening related to egg-donor pregnancies are listed as not reimbursable unless the member's plan specifically allows them.

Definitions and Confirmatory Testing

inv-11: Confirmatory testing — diagnostic procedures such as CVS or amniocentesis offered after equivocal or positive screening results

DefinitionDiagnostic procedures such as chorionic villus sampling (CVS) or amniocentesis offered after equivocal or positive screening results to establish fetal karyotype.

Policy positionConfirmatory testing (CVS or amniocentesis) should be offered and may be reimbursable for women wishing to pursue additional testing following equivocal or positive screening results.

When reimbursableMay be reimbursable when performed as clinical follow-up to an equivocal or positive prenatal screening result as described in the policy.

Provider responsibilityProviders should document the indication (equivocal or positive screening result) when submitting claims for confirmatory diagnostic testing.

inv-12: Penta screen — multi-marker screening panel including hCG, AFP, UE3, DIA with nuchal translucency, and hyperglycosylated hCG

DefinitionA multi-marker screening panel including hCG, AFP, UE3, DIA with nuchal translucency (NT), and hyperglycosylated hCG.

Policy stanceThe use of the 'penta' screen to detect fetal aneuploidy is not reimbursable under this policy.

Related restrictionParallel or simultaneous testing with multiple screening methodologies that include the penta screen is not reimbursable.

Implication for AFP screeningAlpha‑fetoprotein screening may be reimbursable between 16 and 20 weeks when NOT performed as part of a 'penta' screen.

Background — Prenatal Screening Overview

Prenatal screening is performed to identify pregnancies at increased risk for fetal aneuploidies such as trisomy 21, 18, and 13. Common screening approaches include serum marker testing (for example, alpha‑fetoprotein and other analytes) and ultrasound assessment of nuchal translucency (NT)confirmatory diagnostic testing via chorionic villus sampling (CVS) or amniocentesis. This policy permits a single alpha‑fetoprotein (AFP) screen between 16 and 20 weeks when it is not performed as part of a prohibited penta panel, and emphasizes that screening performance and interpretation vary by method and gestational age.