Currentblue cross blue shield - tennesseePolicy N/A

Prenatal Screening -Nongenetic

Defines coverage criteria, indications, and limitations for routine prenatal (nongenetic) screening tests (infectious disease screening, diabetes screening, blood type/Rh, CBC/anemia, GBS, urinalysis, immunity testing, FFN) and identifies tests that do not meet coverage. Applies to pregnant individuals; government policy overrides when conflicting.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPrenatal Screening -Nongenetic

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionVerify member benefits and applicable Medicare/Medicaid rules prior to requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported in this briefing.

15+Routine covered screening items listed

3Tests explicitly listed as not covered

1Conditional FFN indication set

~70Procedure codes referenced

Coverage Summary

This policy defines coverage for routine prenatal nongenetic screening in pregnant individuals and takes a mixed stance: it supports a set of routine screening tests while specifying conditional coverage and explicit noncoverage for certain tests. Headline scope: covered routine prenatal nongenetic screening includes infectious disease screening (HIV, chlamydia, gonorrhea, hepatitis B and C, syphilis), diabetes screening (type 2 at first prenatal visit and gestational diabetes at 24-28 weeks), blood type/Rh and antibody testing with repeat Rh antibody testing at 24-28 weeks for unsensitized Rh (D)-negative individuals, CBC/anemia screening, Group B Streptococcus screening (recommended at 36 0/7–37 6/7 weeks), urinalysis/urine culture, and immunity testing (rubella/varicella). Conditional coverage includes third-trimester re-screening of selected infections for individuals meeting high-risk criteria and fetal fibronectin (FFN) assays when all specific clinical criteria are met; not-covered items include routine hCG testing in normal pregnancy, FFN outside the stated indications, and serial salivary estriol monitoring.

Policy thresholds and timing windows

Gestational diabetes screening window24-28 weeks gestation (and at first prenatal visit if risk factors present)

FFN symptomatic testing window24 to <35 weeks' gestation (symptomatic preterm labor with intact membranes, singleton/twin, cervical dilation <3 cm)

Repeat Rh(D) antibody testing timing24-28 weeks' gestation for unsensitized Rh(D)-negative individuals (unless biological father known Rh-negative)

GBS screening timing36 0/7 to 37 6/7 weeks' gestation (single antepartum screen)

Medical Necessity / Coverage Criteria

Routine prenatal screening that meets coverage criteria

The following routine prenatal screening MEETS COVERAGE CRITERIA for all pregnant individuals:

ALL of the following

Screening for HIV infection.
Screening for Chlamydia trachomatis infection.
Screening for Neisseria gonorrhea infection.
Screening for hepatitis B.
Screening for syphilis.
Screening for hepatitis C.
Screening for type 2 diabetes at the first prenatal visit.
Screening for gestational diabetes during gestational weeks 24 - 28 and at the first prenatal visit if risk factors are present.24-28 weeks
Determination of blood type, Rh(D) status, and antibody status during the first prenatal visit.
Repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative individuals at 24 to 28 weeks' gestation, unless the biological father is known to be Rh (D)-negative.24-28 weeks
Screening for anemia with a CBC or hemoglobin and hematocrit with mean corpuscular volume.
Screening for Group B strep once, recommended during gestational weeks 36 to 37.36 0/7 to 37 6/7 weeks
Urinalysis and urine culture.
Rubella antibody testing.
Testing for varicella immunity.
Screening for tuberculosis in pregnant individuals deemed to be at high risk for TB.

Third trimester re-screening of selected infections (conditional coverage)

Third trimester re-screening MEETS COVERAGE CRITERIA when any of the following high-risk criteria are met:

ONE of

Individual under 25 years of age.
Individual with new or multiple sexual partners.
Individual with a history of sexually transmitted infections (examples: bacterial vaginosis, chancroid, chlamydia, gonorrhea, genital herpes, hepatitis B, hepatitis C, HIV/AIDS, HPV, lymphogranuloma venereum, syphilis, trichomoniasis).
Individual with past or current injection drug use.

Fetal fibronectin (FFN) assays - medically necessary criteria

FFN assays MEET COVERAGE CRITERIA when ALL of the following are met:

ALL of the following

Singleton or twin gestations;
Intact membranes;
Cervical dilation <3 cm;<3 cm
Individual is experiencing symptoms suggestive of preterm labor between 24 and less than 35 weeks' gestation.24 to <35 weeks

Procedure & Billing Codes

Covered CPT/HCPCS procedure codes referencedCPTCovered

80055	Obstetric panel (specified components required)
80081	Obstetric panel (includes HIV testing; specified components required)
81001	Urinalysis, automated, with microscopy
81002	Urinalysis, non-automated, without microscopy
81003	Urinalysis, automated, without microscopy
81007	Urinalysis; bacteriuria screen, except by culture or dipstick
81015	Urinalysis; microscopic only
82677	Estriol
82731	Fetal fibronectin, cervicovaginal secretions, semi-quantitative
82947	Glucose; quantitative, blood

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Procedure codes referenced in policyCPT

82947	Code Description = Glucose; quantitative, blood (eg, glucose)
82950	Code Description = Glucose; tolerance test (GTT), 2 specimens (includes glucose)
82951	Code Description = Glucose; tolerance test (GTT), 3 specimens (includes glucose)
82962	Code Description = Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use
83020	Code Description = Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F)
83021	Code Description = Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F)
83036	Code Description = Hemoglobin; glycosylated (A1C)
84702	Code Description = Gonadotropin, chorionic (hCG); quantitative
84703	Code Description = Gonadotropin, chorionic (hCG); qualitative
84704	Code Description = Gonadotropin, chorionic (hCG); free beta chain

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The procedure codes listed in this policy are provided as general references and may not be all‑inclusive; when billing, providers must report the appropriate CPT, HCPCS, or G-code from the policy’s procedure code list for the prenatal screening performed. This requirement is stated in the policy’s billing guidance and in the CPT/HCPCS procedure code section.

Provider Actions & Documentation

Prior Authorization

FFN assay coverage conditions

Fetal fibronectin (FFN) assays are covered only when all clinical criteria are met. Prior authorization may be required by the member's plan — confirm benefits prior to testing.

82731

Documentation Required

Rh (D)-negative management

Verify the member's Rh (D) status and document management consistent with this policy: determine blood type and Rh(D) status and perform antibody screen at the first prenatal visit; repeat antibody testing for all unsensitized Rh (D)-negative individuals at 24–28 weeks' gestation. Documentation of testing rationale, dates, and results must be retained in the medical record.

86901
86850

Billing Rule

Obstetric panel component requirements

When billing an obstetric panel, include all required component tests as part of the panel submission. The obstetric panel must comprise CBC, hepatitis B surface antigen (HBsAg), rubella antibody, syphilis non-treponemal test, antibody screen, and ABO and Rh typing. Note: CPT 80081 includes an HIV test as part of its components. Ensure individual component tests are performed and documented when submitting CPT codes for the panel.

80055
80081

Documentation Required

Verify member benefits and program rules

Apply benefit coverage based on the individual's specific plan — coverage for prenatal screening services (including whether prior authorization is required, member cost-sharing, and any program-specific rules) depends on the member's contract at the time of service. Verify eligibility, benefits, and prior authorization requirements before ordering or performing testing.

Also ensure use of the correct CPT and G-codes for prenatal screening procedures when submitting claims: include panel codes (e.g., 80055, 80081), individual chemistry/hematology/infectious disease CPT codes, FFN assay CPT 82731 when applicable, and blood typing/antibody screen codes (e.g., 86901, 86850).

Background & Evidence

Clinical background: prenatal nongenetic screening is offered to asymptomatic pregnant individuals to identify conditions that may affect pregnancy outcomes and enable early prevention or treatment. Guideline concordance: recommendations and evidence cited in the policy align with major bodies including ACOG, USPSTF, CDC, WHO, ADA, and VA/DoD. The policy emphasizes screening (for example, anemia, blood typing/Rh, infectious diseases, GDM screening at ≥24 weeks, and GBS screening) as part of routine prenatal care to reduce maternal and neonatal morbidity and mortality.

Key evidence

CDC congenital syphilis prevention88.2% of congenital syphilis cases avoided with proper screening

GBS invasive neonatal rate reductionDeclined from ~2–3 per 1,000 live births pre-screening to 0.5 per 1,000 after screening implementation

References citedGuideline sources include ACOG, CDC, USPSTF, WHO, ADA, HRSA, VA/DoD (among others)

Term	Definition
FFN	Fetal fibronectin
GBS	Group B streptococcal disease
HBsAg	Hepatitis B surface antigen
HCV	Hepatitis C virus

OpenPayer

Prenatal Screening -Nongenetic

Coverage Summary

Medical Necessity / Coverage Criteria

Not Covered / Limitations

Procedure & Billing Codes

Provider Actions & Documentation

Background & Evidence

Definitions

Revision History