RetiredCareFirstPolicy N/A

Amniocentesis and Chorionic Villus Sampling (CVS)

This retired policy documented clinical indications and coverage stance for amniocentesis and chorionic villus sampling for prenatal genetic diagnosis; it informs providers and payers that the policy is retired and refers to current Global Maternity Care operating procedure. Affects providers and CareFirst coverage determinations.

Policy Summary

PayerCareFirst

PolicyAmniocentesis and Chorionic Villus Sampling (CVS)

Policy CodePolicy N/A

Change TypeRetired

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionFollow CareFirst Operating Procedure 4.01.006A for current reporting and any prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

The policy has been retired and is no longer scheduled for review.

Retired 02/01/2025policy status date

10amniocentesis indications

6CVS indications

Documentation & counselingprocedural prerequisites

Coverage Criteria for Amniocentesis and CVS

inv-01: Amniocentesis - Medically Necessary

Amniocentesis is considered medically necessary when any of the following conditions exists:

Amniocentesis indications: In pregnancies where the woman will be 35 years of age or over at the expected time of delivery; prior pregnancy with a child having a chromosomal (e.g., Down's syndrome) or genetic abnormality or major malformations; a known chromosomal or genetic abnormality in either parent; history of chromosomal or genetic abnormality in a blood relative; history of multiple (three or more) spontaneous abortions in this marriage or in a previous mating of either spouse; fetus at increased risk for a hereditary error of metabolism detectable in vitro; pregnancies with Rh incompatibility sensitization; risk of premature delivery with question of fetal lung maturity (e.g., pre-eclampsia, placenta previa, preterm labor); fetus at increased risk for a neural tube defect (family history of spina bifida or anencephaly in either spouse); abnormal maternal serum alpha-fetoprotein level.presence of any one indication

Source lists ten bullet indications.

inv-02: Chorionic Villus Sampling (CVS) - Medically Necessary

Chorionic villus sampling is medically necessary when any of the following conditions exists:

Policy Summary

PayerCareFirst

PolicyAmniocentesis and Chorionic Villus Sampling (CVS)

Policy CodePolicy N/A

Change TypeRetired

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionFollow CareFirst Operating Procedure 4.01.006A for current reporting and any prior authorization requirements.

SourceLink

On This Page

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inv-03: Fetal Sex Determination for X-linked Disorders

Fetal sex determination via amniocentesis/CVS may be medically necessary for pregnancies at risk for X-linked hereditary disorders when documentation supports increased risk (not for elective sex determination):

X-linked disorder indications: Conditions include hemophilia; X-linked intellectual disability; X-linked hydrocephalus; Duchenne muscular dystrophy. Documentation must support that there is an increased risk of an X-linked disorder and the procedure must not be performed purely for sex determination.documentation of increased risk

Counseling for these procedures is considered medically necessary.

Provider Actions and Authorization

Note

Prior authorization / policy status

This policy has been retired as of 02/01/2025. Follow CareFirst Operating Procedure 4.01.006A, Global Maternity Care, for current authorization and reporting guidelines regarding amniocentesis and chorionic villus sampling (CVS).

Note

Providers should refer to the operating procedure for current provider actions and authorization steps; this placeholder highlights that provider-impact requirements formerly in this policy are now maintained in Operating Procedure 4.01.006A.

Documentation Required

Documentation and counseling for X-linked disorder testing

When fetal sex determination is performed to evaluate risk for an X-linked disorder, documentation must support that there is an increased risk of an X-linked hereditary disorder (e.g., hemophilia, X-linked intellectual disability, X-linked hydrocephalus, Duchenne muscular dystrophy) and that testing is not being done solely for sex determination. Counseling related to these procedures is medically necessary and must be documented.

Examples of X-linked indications: Hemophilia; X-linked intellectual disability; X-linked hydrocephalus; Duchenne muscular dystrophy.
Documentation requirement: record of elevated risk for an X-linked disorder and evidence that testing guides clinical management or counseling.
Counseling: pre- and/or post-test genetic counseling must be provided and documented.

Denial Risk

Denial risk if indications or procedure requirements not met

Services may be denied if they do not meet the listed medical indications or the requirements in CareFirst Operating Procedure 4.01.006A. Examples of medically necessary indications include advanced maternal age (≥35 at expected delivery), prior child with chromosomal/genetic abnormality, known parental chromosomal/genetic abnormality, family history in a blood relative, history of ≥3 spontaneous abortions, increased risk for hereditary metabolic error, Rh sensitization, suspected fetal lung immaturity when early delivery is possible, increased risk for neural tube defect, or abnormal maternal serum alpha‑fetoprotein. CVS-specific indications include many of the same criteria and must meet procedure timing considerations. Documentation supporting the indication is required to avoid denial.

Potential denial if indication not documented or procedure falls outside Operating Procedure 4.01.006A.
Amniocentesis indications (non‑exhaustive): maternal age ≥35 at expected delivery; prior child with chromosomal/genetic abnormality; known parental chromosomal/genetic abnormality; family history in a blood relative; ≥3 spontaneous abortions; increased risk for hereditary metabolic error; Rh incompatibility sensitization; assessment of fetal lung maturity for at‑risk preterm delivery; increased risk for neural tube defect; abnormal maternal serum AFP.
CVS indications (non‑exhaustive): maternal age ≥35 at expected delivery; prior child with chromosomal/genetic abnormality; known parental chromosomal/genetic abnormality; family history in a blood relative; ≥3 spontaneous abortions; increased risk for hereditary metabolic error.

Definitions

Amniocentesis — definition and short description

DefinitionAmniocentesis: procedure involving needle withdrawal of amniotic fluid under local anesthesia and ultrasound guidance for biochemical, serologic, and cytogenetic analysis to diagnose fetal genetic abnormalities, assess fetal lung maturity, and evaluate hemolytic disease; results guide management decisions (timing of delivery, fetal transfusion, counseling).

Typical timingPerformed after the 16th week of gestation for prenatal diagnostic purposes.

Procedure detailsA needle is inserted into the amniotic sac and fluid is withdrawn; fetal cells from the fluid may be cultured for cytogenetic testing.

Clinical usesDiagnostic testing for genetic abnormalities, assessment of fetal lung maturity, and evaluation of hemolytic disease severity in isoimmunization.

Policy noteThis policy is retired as of 02/01/2025; follow CareFirst Operating Procedure 4.01.006A for current reporting and requirements.

Chorionic Villus Sampling (CVS) — definition and short description

DefinitionChorionic Villus Sampling (CVS): prenatal genetic testing by obtaining chorionic villi via transcervical or transabdominal routes under ultrasound guidance to diagnose genetic disease as early as the 8th week of gestation.

Typical timingMay be performed in the later part of the first trimester; can diagnose genetic disease as early as 8 weeks gestation.

Procedure routesSampling methods include transcervical (TC) or transabdominal (TA) approaches using a catheter (TC) or needle (TA) with ultrasonic guidance to aspirate villi.

Comparison to amniocentesisPermits earlier diagnosis (as early as 8 weeks) versus amniocentesis, which is performed after 16 weeks.

Policy noteThis policy is retired as of 02/01/2025; follow CareFirst Operating Procedure 4.01.006A for current reporting and requirements.

OpenPayer

Amniocentesis and Chorionic Villus Sampling (CVS)

Coverage Criteria for Amniocentesis and CVS

Provider Actions and Authorization

Background

Definitions