CurrentCentenePolicy N/A

Preimplantation Genetic Testing (PGT)

Defines medical necessity and investigational determinations for preimplantation genetic testing (PGT-M, PGT-SR, PGT-A) in the context of IVF for members of Centene-affiliated health plans; intended for providers ordering or performing PGT and payers adjudicating claims.

Policy Summary

PayerCentene

PolicyPreimplantation Genetic Testing (PGT)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when plan policy requires review for genetic testing services and document genetic counseling and offer of confirmatory diagnostic testing for PGT-M and PGT-SR.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3PGT categories

6Example procedure codes

NCApplicable state

11/24Last revision

Coverage criteria for Preimplantation Genetic Testing (PGT)

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PGT-M eligibility: The embryo is at an elevated risk of a genetic disorder because of parental status and ONE of the following: (1) both biological parents are known carriers for the same autosomal recessive disorder; OR (2) one biological parent is a known carrier of an autosomal dominant disorder; OR (3) one biological parent is a known carrier of an X-linked recessive disorder.

Codes: 0396U, 89290, 89291, 81479

Preimplantation Genetic Testing for Structural Rearrangements (PGT-SR)

PGT-SR may be considered medically necessary when ALL of the following are met:

PGT-SR eligibility: The embryo is at an elevated risk of a genetic disorder because one biological parent has a chromosomal rearrangement.

Codes: 81228, 81229, 81479, 89290, 89291

Preimplantation Genetic Testing for Aneuploidy (PGT-A)

PGT-A coverage stance:

PGT-A: Preimplantation genetic testing for aneuploidy (PGT-A) is considered investigational for all indications.

Codes: 81229, 81479, 89290, 89291, 0254U

PGT-M and PGT-SR are covered only when used for the specific parental-risk indications described in this policy. PGT-M may be considered medically necessary when the embryo is at elevated risk because both biological parents are carriers of the same autosomal recessive disorder, or one biological parent is a known carrier of an autosomal dominant or X-linked recessive disorder. PGT-SR may be considered medically necessary when the embryo is at elevated risk because one biological parent has a chromosomal rearrangement. Both PGT-M and PGT-SR are considered investigational for indications other than the parental carrier or chromosomal rearrangement criteria described above.

Relevant procedure and diagnosis codes

Commonly referenced PGT procedure/PLA codesmixed

81229	Preimplantation genetic testing (example listed under PGT-A/PGT-SR)
81479	Unlisted molecular pathology procedure (listed across PGT types)
89290	Embryo biopsy (listed across PGT types)
89291	Embryo biopsy, additional (listed across PGT types)
0254U	PLA/Proprietary PGT-A code example (SMART PGT-A)

PGT-M example PLA codeCPT

0396U

PLA/Proprietary PGT-M example code

PGT-SR related codesCPT

81228

PGT-SR related molecular cytogenetics code

Example ICD codes referencedICD-10

N97.0	Female infertility due to tubal origin (example ICD listed)
N97.9	Female infertility, unspecified (example ICD listed)
Z31	Encounter for procreative management (example ICD listed)
Z14.8	Genetic carrier status and related codes (example ICD listed)
214.8	Other specified congenital malformations (example ICD listed)
231	Example ICD listed in table (document contains truncated entries)

Provider requirements, prior authorization, and counseling

Prior Authorization

Medical necessity-based prior authorization for PGT-M and PGT-SR

Preimplantation genetic testing for monogenic disorders (PGT-M) and preimplantation genetic testing for structural rearrangements (PGT-SR) may be considered medically necessary when the policy's specified parental carrier or chromosomal rearrangement criteria are met; prior authorization should be obtained where the plan requires review for genetic testing services.

PGT-M may be considered medically necessary when the embryo is at elevated risk because both parents are carriers of the same autosomal recessive disorder, one parent is a carrier of an autosomal dominant disorder, or one parent is a carrier of an X-linked recessive disorder (codes: 0396U, 89290, 89291, 81479).
PGT-SR may be considered medically necessary when the embryo is at elevated risk because one biological parent has a chromosomal rearrangement (codes: 81228, 81229, 81479, 89290, 89291).

Step Therapy

Step therapy not specified

No step therapy requirements are specified in this policy for preimplantation genetic testing.

Documentation Required

Genetic counseling and offer of confirmatory diagnostic testing

Offer genetic counseling by a qualified genetics professional and document the counseling and the offer of confirmatory diagnostic testing; for patients undergoing PGT-M or PGT-SR, offer confirmation of results with chorionic villus sampling (CVS) or amniocentesis.

Genetic counseling should be performed by an individual with experience in genetic medicine and testing methods (e.g., genetic counselor, medical geneticist, or advanced practice practitioner specializing in genetics).
All patients who undergo PGT-M or PGT-SR should be offered diagnostic testing via CVS or amniocentesis for confirmation of results.

Denial Risk

PGT-A is investigational — potential denials

Preimplantation genetic testing for aneuploidy (PGT-A) is considered investigational for all indications; claims for PGT-A may be denied on that basis.

PGT-A is listed as investigational with associated codes 81229, 81479, 89290, 89291, 0254U.

Background on preimplantation genetic testing

Preimplantation genetic testing (PGT) is a laboratory testing strategy performed on cells biopsied from embryos as part of in vitro fertilization (IVF). The testing is intended either to detect a specific single-gene inherited disorder (PGT-M), to detect structural chromosomal rearrangements when a parent is a carrier (PGT-SR), or to screen embryos for chromosomal aneuploidy (PGT-A). For PGT-M, medical necessity is limited to embryos at elevated risk because both parents are carriers of the same autosomal recessive disorder or one parent is a carrier of an autosomal dominant or X-linked recessive disorder. For PGT-SR, medical necessity is limited to embryos at elevated risk because one biological parent has a chromosomal rearrangement. PGT-A is considered investigational by this policy.

Definitions of PGT types

PGT-M — definition / short description

TermPreimplantation genetic testing for monogenic disorders (PGT-M)

Short descriptionTargeted genetic testing of biopsied embryo cells during IVF to detect a specific single-gene inherited disorder and help prevent birth of affected children when parents are at increased transmission risk.

When consideredMay be medically necessary when the embryo is at elevated risk because parents are known carriers of a relevant monogenic disorder (e.g., both parents carriers for the same autosomal recessive disorder, one parent a carrier of an autosomal dominant disorder, or one parent a carrier of an X-linked recessive disorder).

Recommended actionsOffer genetic counseling by a qualified genetics professional and offer diagnostic confirmation in pregnancy (CVS or amniocentesis) for PGT-M results.

PGT-SR — definition / short description

TermPreimplantation genetic testing for structural rearrangements (PGT-SR)

Short descriptionTesting of biopsied embryo cells during IVF to detect structural chromosomal abnormalities (for example, parental translocations) that increase risk of unbalanced rearrangements in offspring.

When consideredMay be medically necessary when the embryo is at elevated risk because one biological parent carries a chromosomal rearrangement.

Recommended actionsOffer genetic counseling by an experienced genetics professional and offer diagnostic confirmation in pregnancy (CVS or amniocentesis) for PGT-SR results.

PGT-A — definition / investigational note

TermPreimplantation genetic testing for aneuploidy (PGT-A)

Short descriptionUntargeted screening of biopsied embryo cells during IVF to detect chromosomal aneuploidy across chromosomes.

Policy stancePGT-A is considered investigational for all indications under this policy and is not medically necessary per the document.

Professional guidanceProfessional societies note insufficient evidence to recommend routine use of PGT-A for all IVF patients and call for further well‑controlled studies to define clinical utility.