CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preimplantation genetic testing (PGT/PGD/PGS) as adjunct to IVF

Defines medical necessity, coverage, exclusions, prior authorization, and CPT coding for preimplantation genetic diagnosis (PGT-M/PGT-SR) and preimplantation genetic screening (PGT-A/PGS) as adjuncts to in vitro fertilization for Medicare Advantage and Commercial products offered by Blue Cross Blue Shield Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreimplantation genetic testing (PGT/PGD/PGS) as adjunct to IVF

Policy CodePolicy N/A

Change TypeClarified coverage distinctions

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for preimplantation genetic diagnosis for Medicare Advantage Plans and follow recommended prior authorization for Commercial Products via the online portal; only the ordering physician may request authorization.

SourceLink

POLICY UPDATE CHANGES

Policy distinguishes medically necessary PGT-M/PGT-SR for identified elevated genetic risk from PGT-A (screening), which is not covered/medically unnecessary in most situations.

2CPT codes listed

PGT-M/PGT-SRCovered indications (conditional)

PGT-A/PGSNot covered / Not medically necessary

Coverage Summary

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Preimplantation genetic testing includes diagnostic methods (PGT-M/PGT-SR) and screening (PGT-A) performed on oocytes or embryos as an adjunct to in vitro fertilization (IVF). PGT-M/PGT-SR may be considered medically necessary when there is an identified elevated genetic risk (for example, parental carriers of single-gene disorders or parental chromosomal translocations) and is available for both Medicare Advantage and Commercial products with prior authorization requirements. In contrast, PGT-A (screening for aneuploidy) is generally not covered / not medically necessary for Medicare Advantage and Commercial products because the evidence is insufficient to demonstrate an overall net health benefit, although some subgroup benefit has been reported in the literature. CPT biopsy codes 89290 and 89291 are listed as covered when medical criteria are met. Policy last reviewed on 2026-01-01.

Quick facts

SubjectPreimplantation genetic testing (PGT/PGD/PGS) as adjunct to IVF

ScopeDefines medical necessity, coverage, exclusions, prior authorization, and CPT coding for PGT-M/PGT-SR and PGT-A/PGS for Medicare Advantage and Commercial products offered by BCBSRI

StatusCURRENT

Last review2026-01-01

CPT codes listed2 (89290, 89291)

Covered indications (conditional)PGT-M / PGT-SR when specified medical criteria met (e.g., parental carriers, translocation)

Not covered / Not medically necessaryPGT-A / PGS in most situations; PGT-M/PGT-SR outside specified criteria

Medical-Necessity Criteria

Medically Necessary: Preimplantation Genetic Diagnosis (PGT-M / PGT-SR)

Preimplantation genetic diagnosis may be considered medically necessary as an adjunct to IVF when ONE of the following specific elevated risks is present:

Medically Necessary Indications

Autosomal recessive - both parents carriers: Both parents are known carriers of a single-gene autosomal recessive disorder.
Autosomal recessive - one parent carrier with affected child: One parent is a known carrier of a single-gene autosomal recessive disorder, and the parents have an offspring who has been diagnosed with that recessive disorder.
Autosomal dominant carrier: One parent is a known carrier of a single-gene autosomal dominant disorder.
X-linked carrier: One parent is a known carrier of a single X-linked disorder.
Parental translocation: Parent with balanced or unbalanced chromosomal translocation (evaluation of an embryo at an identified elevated risk of structural chromosomal abnormality).

Not Covered / Not Medically Necessary

Not Covered / Not Medically Necessary: Preimplantation Genetic Screening (PGT-A / PGS)

PGT-M / PGT-SR performed outside the medical criteria specified above is not covered or is considered not medically necessary according to product.

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Evidence for PGT-A: Randomized controlled trials and meta-analyses of older screening methods (eg, FISH) found lower or similar ongoing pregnancy and live birth rates compared with IVF without PGT-A. Fewer RCTs exist for newer comprehensive chromosome screening techniques; results are mixed, and recent meta-analyses report possible benefits in specific subgroups (for example, advanced maternal age). Overall, the evidence is insufficient to determine a net health benefit for PGT-A across all populations.

Evidence for PGT-M/PGT-SR: Observational studies and systematic reviews indicate that PGT-M/PGT-SR performed for individuals with an identified elevated risk is associated with births of unaffected fetuses and a decrease in spontaneous abortions. The evidence from these nonrandomized studies is considered sufficient to conclude a net health benefit when performed for the specified high-risk indications.

Provider Actions

Prior Authorization

Prior authorization required for Medicare Advantage

Prior authorization is required for preimplantation genetic diagnosis for Medicare Advantage Plans.

Prior Authorization

Prior authorization recommended for Commercial Products

Prior authorization is recommended for Commercial Products via the online portal for participating providers.

Documentation Required

Authorization must be obtained by ordering physician

Only the ordering physician shall be involved in the authorization, appeal, or other administrative processes related to prior authorization/medical necessity. Laboratories or third parties are prohibited from obtaining authorization on behalf of the ordering physician or facilitating any portion of the authorization or appeal process; such actions are violations of policy and may result in denial and severe actions up to termination from the provider network.

Denial Risk

Denial and financial liability for unauthorized lab services

If a laboratory provides a laboratory service that has not been authorized, the service will be denied as the financial liability of the participating laboratory and may not be billed to the member.

Background, Evidence & Definitions

Preimplantation genetic testing encompasses techniques in which maternal or embryonic DNA is sampled and analyzed to deselect embryos with genetic defects prior to uterine implantation. Biopsy can be performed at the oocyte (polar body), cleavage-stage embryo (blastomere), or blastocyst (trophectoderm) stages, each with specific advantages and limitations (eg, maternal-only assessment with polar bodies, mosaicism risk with single blastomere analysis, and culture/availability constraints for blastocyst biopsy).

Analyzed material can be tested with methods such as polymerase chain reaction for single-gene defects, fluorescent in situ hybridization (FISH) for selected chromosomes or translocations, and more comprehensive platforms including array comparative genomic hybridization (array CGH) and next-generation sequencing for whole-chromosome analysis and modern PGT-A approaches. Indications include detection of single-gene disorders (PGT-M), structural rearrangements (PGT-SR), and aneuploidy screening (PGT-A).

Topic	Evidence Summary
PGT-M evidence	Observational studies and systematic reviews suggest PGT-M for identified elevated risk is associated with birth of unaffected fetuses and decreased spontaneous abortions; evidence sufficient to determine improvement in net health outcome.
PGT-A evidence	Randomized controlled trials and meta-analyses of initial PGT-A methods show lower or similar outcomes; fewer RCTs on newer methods with mixed findings and insufficient evidence overall to determine net health benefit, with possible subgroup benefit (eg, advanced maternal age).

Term	Definition
PGT-A	Preimplantation genetic testing for aneuploidy (PGT-A) is used to screen for chromosomal aneuploidy in conjunction with IVF for couples.
PGT-M	Preimplantation genetic testing for monogenic disorders (PGT-M) are used to detect a specific single gene inherited disorder or chromosome rearrangement in conjunction with in vitro fertilization (IVF).
PGT-SR	Preimplantation genetic testing for structural rearrangements (PGT-SR) are used to detect a chromosome rearrangement in conjunction with in vitro fertilization (IVF).

Revision History

Jan 2026policy_updateLatest

Policy distinguishes medically necessary PGT-M/PGT-SR for identified elevated genetic risk from PGT-A (screening), which is not covered/medically unnecessary in most situations. No specific clinical or coding changes indicated; published updates listed.

Nov 2024policy_update

Nov 2023policy_update