Currentblue cross blue shield - tennesseePolicy N/A

Prenatal Testing (Nongenetic)

Defines coverage for routine nongenetic prenatal screening tests (infectious disease, blood tests, glucose screening, GBS, FFN, urinalysis, etc.) for pregnant individuals and notes limitations for certain tests.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPrenatal Testing (Nongenetic) — coverage criteria for routine nongenetic prenatal screening tests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument indications and timing for routine prenatal screening and use the listed obstetric panel and urinalysis codes when billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~80procedure and laboratory codes listed

80055/80081obstetric panel codes listed

36-37 weeksGBS timing

<6.5%A1C preconception target

99.5%FFN NPV (7 days)

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Covered routine prenatal screening

Routine prenatal screening tests that meet coverage criteria

Routine prenatal screening covered items: The following routine prenatal screening MEETS COVERAGE CRITERIA for all pregnant individuals: antigen/antibody combination assay screening for HIV; screening for Chlamydia trachomatis; screening for Neisseria gonorrhoeae; triple panel screening for hepatitis B (HBsAg, anti-HBs, total anti-HBc); screening for syphilis; antibody screening for hepatitis C; screening for type 2 diabetes at the first prenatal visit; screening for gestational diabetes during weeks 24-28 and at the first prenatal visit if risk factors are present; determination of blood type, Rh(D) status, and antibody status at the first prenatal visit with repeat Rh(D) antibody testing at 24-28 weeks for unsensitized Rh(D)-negative individuals unless the biological father is Rh(D)-negative; screening for anemia with CBC or H/H with MCV; Group B streptococcal screening once per pregnancy (recommended 36-37 weeks); urinalysis and urine culture; rubella antibody testing; testing for varicella immunity; screening for tuberculosis when at high risk.

FFN for suspected preterm labor

Specialty covered indication

Fetal fibronectin use: For individuals with singleton or twin pregnancies presenting in the ambulatory setting with signs or symptoms of preterm labor, fetal fibronectin (FFN) assay MEETS COVERAGE CRITERIA.

FFN has high negative predictive value for delivery within 7-14 days.

Not medically necessary / Not covered tests

Not covered due to insufficient evidence

Not covered tests: Human chorionic gonadotropin (hCG) hormone testing for individuals with a normal pregnancy without complications DOES NOT MEET COVERAGE CRITERIA; serial monitoring of salivary estriol levels as a technique of risk assessment for preterm labor DOES NOT MEET COVERAGE CRITERIA.

Covered when guideline criteria are met

Covered when meeting guideline-recommended universal or risk-based criteria:

Universal prenatal screening: Screening for HIV, syphilis, hepatitis B, and hepatitis C is recommended for all pregnant individuals at the first prenatal visit; HIV and HBV may be retested in the third trimester or at delivery if at increased risk.

(CDC, 2024b)

Risk-based rescreening for STIs: Chlamydia and gonorrhea screening is recommended at the first prenatal visit and rescreening in the third trimester for individuals <25 years or those at increased risk; individuals treated for gonorrhea should be retested within 3 months.

(CDC)

Diabetes screening and preconception care: Preconception counseling and glycemic optimization (A1C target <6.5% when safe) are recommended for individuals with preexisting diabetes; screen for gestational diabetes after 24 weeks and screen for preexisting diabetes at the first prenatal visit if risk factors are present.A1C <6.5%

The policy excludes certain tests from routine prenatal coverage. Human chorionic gonadotropin (hCG) hormone testing for individuals with a normal pregnancy without complications does not meet coverage criteria. The policy also excludes serial monitoring of salivary estriol levels when used as a technique to assess risk for preterm labor, which does not meet coverage criteria.

Routine screening for certain genital and vaginal infections is not supported for asymptomatic pregnant individuals. Specifically, the evidence does not support routine screening for Bacterial vaginosis or Trichomonas vaginalis in asymptomatic patients. In addition, HSV-2 serologic screening is not supported for asymptomatic pregnant individuals, though type-specific serology may be useful for counseling in select circumstances; symptomatic individuals should be evaluated and treated.

Procedure and billing codes listed in this Medical Policy are provided only as a general reference. They are intended to assist with coding but may not be all-inclusive; providers should verify code applicability and payer requirements before submission.

Serial salivary estriol monitoring for preterm labor risk is specifically addressed and does not meet coverage criteria. The policy states that using repeated salivary estriol measurements as a technique to assess preterm labor or delivery risk is excluded from coverage due to insufficient supporting evidence.

The policy indicates that routine, serial cultures for herpes simplex virus in the third trimester are not indicated for patients with a history of recurrent genital herpes. Testing and management should be guided by symptoms and clinical judgment rather than routine serial culture in the third trimester.

Procedure and Laboratory Codes

Applicable CPT/HCPCS Procedure CodesCPT

80055	Obstetric panel: CBC, HBsAg, rubella antibody, syphilis test, antibody screen, ABO and Rh blood typing
80081	Obstetric panel (includes HIV testing): CBC, HBsAg, HIV-1 Ag/Ab, rubella antibody, syphilis test, antibody screen, ABO and Rh blood typing
81001	Urinalysis, automated, with microscopy
81002	Urinalysis, non-automated, without microscopy

Obstetric panel and urinalysis CPT codesCPTCovered

80055	Obstetric panel (CBC with differential variants; HBsAg; rubella antibody; syphilis non-treponemal; RBC antibody screen; ABO and Rh typing)
80081	Obstetric panel (includes HIV testing) (CBC with differential variants; HBsAg; HIV-1 antigen/antibody; rubella antibody; syphilis non-treponemal; RBC antibody screen; ABO and Rh typing)
81001	Urinalysis, dip stick or tablet reagent; automated, with microscopy
81002	Urinalysis, dip stick or tablet reagent; non-automated, without microscopy

Additional covered procedure and lab codes referencedmixedCovered

81003	Urinalysis; automated, without microscopy
81007	Urinalysis; bacteriuria screen
81015	Urinalysis; microscopic only
82677	Estriol
82731	Fetal fibronectin, cervicovaginal secretions, semi-quantitative
82947	Glucose; quantitative, blood
82950	Glucose; post glucose dose (includes glucose)
82951	Glucose tolerance test (3 specimens)
82962	Glucose, blood by home glucose monitoring device
83036	Hemoglobin A1C

1–10 of 61

1/7

Preconception A1C target

Preconception A1C targetADA recommends A1C <6.5% (48 mmol/mol) when planning pregnancy

When to begin counselingIncorporate preconception counseling starting at puberty for individuals with diabetes and reproductive potential

PurposeOptimize glycemic control to reduce risk of congenital anomalies, preeclampsia, macrosomia, preterm birth

Glucose tolerance test (3 specimens, CPT 82951)

Glucose tolerance test (GTT)3 specimens (CPT 82951)

IncludesPost-glucose dose measurement and standard 3-specimen sampling

Related codesCPT 82950 (post glucose dose), CPT 82947 (glucose quantitative)

Provider Actions, Billing, and Documentation

Prior Authorization

Prior authorization — routine prenatal screening

Prior authorization is not specified for routine prenatal screening listed below; verify individual benefit coverage and any payer-specific prior authorization requirements before performing services.

Verify member benefits for prior authorization requirements when applicable.
Third-trimester re-screening for <25-year-olds or continued high-risk individuals meets coverage criteria (no PA specified).
FFN assay for preterm labor in symptomatic singleton or twin pregnancies meets coverage criteria (no PA specified).

Billing Rule

Use listed CPT/HCPCS codes — billing recommendation for obstetric panels and urinalysis

When billing obstetric panels and urinalysis, report the listed CPT/HCPCS codes that correspond to the performed components. Ensure the obstetric panel billed includes all required component tests as defined by the CPT code description.

80055 or 80081 — bill when the full obstetric panel components are performed. 80081 includes HIV testing.
81001 (automated with microscopy) or 81002 (non-automated without microscopy) — bill based on urinalysis method performed.
Document each component test performed to support the panel code billed.

Prior Authorization

Potential prior authorization for listed HCPCS codes

Some listed HCPCS/CPT codes may require review under payer-specific prior authorization or benefit rules; confirm with plan before performing non-routine or repeated testing.

S3652 (saliva test, hormone level; to assess preterm labor risk) — listed but note: serial salivary estriol monitoring DOES NOT MEET COVERAGE CRITERIA.
G0472 — hepatitis C antibody screening covered for high-risk individuals or other covered indications; verify indication.
Nucleic acid/antigen detection codes (87591–87850) — bill as indicated for chlamydia, gonorrhea, and group B strep testing.

Step Therapy

Step therapy — none specified

No step therapy requirements are specified for routine prenatal screening in this policy.

Documentation Required

Document indication and timing for routine prenatal screening

Document the clinical indication and timing for all routine prenatal screening performed (e.g., initial prenatal visit, 24–28 weeks, 36–37 weeks for GBS, third trimester re-screening when indicated).

Record gestational age and risk factors when ordering gestational diabetes screening or third-trimester re-screening.
For Rh (D)-negative unsensitized individuals, document repeat antibody testing at 24–28 weeks unless paternal Rh (D)-negative is known.

Documentation Required

Procedure code documentation — document use of obstetric panel and urinalysis codes as appropriate

When using obstetric panel and urinalysis procedure codes, document the specific component tests and methods (e.g., automated CBC with differential vs. automated CBC with manual differential; urinalysis automated with microscopy vs. non-automated without microscopy).

For 80055/80081, list component CPTs where possible (CBC method, HBsAg, rubella Ab, syphilis non-treponemal test, RBC antibody screen, ABO and Rh typing).
For urinalysis, indicate whether automated with microscopy (81001) or non-automated without microscopy (81002) was performed.

Billing Rule

Required components for obstetric panels

Obstetric panels must include all required elements listed in the CPT code definition; missing components may affect appropriate use of the panel code.

Required components include CBC with appropriate differential, HBsAg, rubella antibody, syphilis non-treponemal test, RBC antibody screen, ABO and Rh (D) typing.
80081 specifically includes HIV testing as part of the panel.

Denial Risk

hCG testing not covered — human chorionic gonadotropin testing exclusion for normal uncomplicated pregnancy

Human chorionic gonadotropin (hCG) testing for a normal, uncomplicated pregnancy is excluded from coverage and should not be billed as a covered prenatal screening test.

Do not order or bill hCG testing for routine monitoring of a normal, uncomplicated pregnancy.
Document clinical justification if hCG testing is performed for a non-routine indication.

Denial Risk

Salivary estriol monitoring not covered — serial monitoring exclusion

Serial monitoring of salivary estriol levels as a technique for preterm labor risk assessment is not covered and should not be billed as a covered service.

S3652 (saliva test, hormone level; to assess preterm labor risk) is listed in the code section but serial use is non-covered.
If used for experimental or investigational purposes, obtain prior authorization or document noncoverage discussion with the member.

Note

Conflict with government policy — government policy takes precedence

If this policy conflicts with any applicable government policy (e.g., LCDs/NCDs or state Medicaid rules), the government policy takes precedence for affected members.

Verify Medicare/Medicaid-specific coverage rules and follow applicable LCDs/NCDs or state regulations where they differ from this policy.

Billing Rule

Procedure codes are reference-only (billing caveat)

Procedure codes listed in this policy are provided for reference only and may not be exhaustive. Use clinical documentation to support billed services and check payer billing guidelines.

Codes include but are not limited to: obstetric panels (80055, 80081), urinalysis (81001, 81002), infectious agent detection (87591–87850), CBC (G0306, G0307), hepatitis C screening (G0472).
Always ensure documentation supports the selected code and the medical necessity of the test.

Definitions and Key Terms

FFN

DefinitionFetal fibronectin (FFN): a protein found between the uterine lining and amniotic sac used as a biomarker in pregnancy

UseAssesses risk of preterm delivery in symptomatic patients

Test codesCPT 82731 (fetal fibronectin, semi-quantitative); HCPCS S3652 (saliva fetal fibronectin referenced)

GBS (Group B streptococcal disease)

DefinitionGBS = Group B streptococcal disease

Screening timingScreen once per pregnancy, recommended at 36-37 weeks

Detection method codesNAAT/Gene amplification and antigen detection codes (e.g., CPT 87653, 87802) referenced in policy code lists

HDFN (Hemolytic disease of the fetus and newborn)

DefinitionHDFN = Hemolytic disease of the fetus and newborn

Related testingIncludes antibody screen (CPT 86850) and blood typing ABO/Rh (CPT 86900, 86901) as part of obstetric panel

PurposeDetects maternal alloimmunization risk to guide management and repeat testing as indicated

Preconception counseling (ADA A1C <6.5% recommendation)

Preconception counseling roleShould be incorporated into routine diabetes care beginning at puberty for those with reproductive potential

Focus areasAchieving glycemic targets, nutrition, diabetes education, screening for comorbidities and complications

MonitoringDilated eye exams before pregnancy or in first trimester and monitored each trimester as indicated

CPT 80055/80081 obstetric panels components summary

80055 componentsCBC (85025/85027 plus 85004 OR 85027 plus manual diff 85007/85009), HBsAg (87340), Rubella antibody (86762), Syphilis non-treponemal test (86592), RBC antibody screen (86850), ABO typing (86900), Rh(D) typing (86901)

80081 additional componentIncludes HIV-1 Ag/Ab testing (87389) in addition to 80055 components

Urinalysis codes81001 (automated with microscopy) and 81002 (non-automated without microscopy) commonly billed with panels

Obstetric panel (80055/80081) definition and components

DefinitionObstetric panel (CPT 80055/80081): bundled prenatal laboratory panel required for first prenatal visit or as clinically indicated

Core componentsCBC with appropriate differential, HBsAg, rubella antibody, syphilis non-treponemal test, RBC antibody screen, ABO and Rh typing

Distinction80081 includes HIV testing (HIV-1 antigen/antibody) while 80055 does not

Fetal fibronectin testing (CPT 82731 or HCPCS S3652) definition

DefinitionFetal fibronectin testing: cervicovaginal assay used to assess risk of preterm delivery in symptomatic patients

Billing codesCPT 82731 (fetal fibronectin, semi-quantitative) or HCPCS S3652 (saliva fetal fibronectin referenced)

Clinical use noteHigh negative predictive value for delivery within 7-14 days when used in symptomatic patients

OpenPayer

Prenatal Testing (Nongenetic)

Coverage Criteria — Routine Prenatal Screening

Procedure and Laboratory Codes

Provider Actions, Billing, and Documentation

Background and Purpose

Definitions and Key Terms