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    v1.0.30
    OpenPayerPolicy UpdatesGenetic & Molecular TestingColorado Rocky Mountain Fetal DNA Coverage | OpenP…
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    CurrentColorado Rocky Mountain Health PlansPolicy CS085KS.05

    Cell-Free Fetal DNA Testing (for Kansas Only)

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    This policy governs coverage review for DNA-based noninvasive prenatal testing, including cell-free fetal DNA testing, for members in Kansas. Medical necessity criteria are incorporated by reference to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual.

    Policy Summary
    PayerColorado Rocky Mountain Health Plans
    PolicyCell-Free Fetal DNA Testing (for Kansas Only)
    Policy CodePolicy CS085KS.05
    Change TypeRevised
    Effective DateNov 1, 2026
    Next Review DateNot specified
    Key ActionMaintain legible medical record documentation supporting medical necessity, including relevant history, physical examination, and pertinent diagnostic results.
    SourceLink
    POLICY UPDATE CHANGES

    The applicable code list was updated to reflect quarterly edits and code 0663U was added.

    1Applicable state
    9Listed applicable procedure codes
    3

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    Policy pages
    0663UCode added in the current revision

    Coverage Criteria

    DNA-based noninvasive prenatal tests of fetal aneuploidy

    Refer to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for medical necessity clinical coverage criteria.

    External Kansas criteria: Medical necessity clinical coverage criteria for DNA-based noninvasive prenatal tests of fetal aneuploidy are established in the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual.

    This policy does not reproduce the criteria.

    FDA approval or clearance alone is not a basis for coverage. Coverage is determined under the applicable benefit, contractual, legal, and medical-necessity requirements.

    Covered Indications

    DNA-based noninvasive prenatal tests of fetal aneuploidy

    Medical necessity criteria are delegated to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual.

    External Kansas criteria: Medical necessity clinical coverage criteria for DNA-based noninvasive prenatal tests of fetal aneuploidy are established in the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual.

    This policy does not reproduce the criteria.

    Applicable Codes

    Applicable CPT CodesCPT
    0488UFetal DNA in maternal blood obstetrics (fetal antigen noninvasive prenatal test), cell-free DNA sequence analysis for detection of fetal presence or absence of 1 or more of the Rh, C, c, D, E, Duffy (Fya), or Kell (K) antigen in alloimmunized pregnancies, reported as selected antigen(s) detected or not detected
    0489UObstetrics (single-gene noninvasive prenatal test), cell-free DNA sequence analysis of 1 or more targets (e.g., CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pathogenic variants, and relative mutation-dosage analysis based on molecular counts to determine fetal inheritance of maternal mutation, algorithm reported as a fetal risk score for the condition (e.g., cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia)
    0494URed blood cell antigen (fetal RhD gene analysis), next-generation sequencing of circulating cell-free DNA (cfDNA) of blood in pregnant individuals known to be RhD negative, reported as positive or negative
    0536URed blood cell antigen (fetal RhD), PCR analysis of exon 4 of RHD gene and housekeeping control gene GAPDH from whole blood in pregnant individuals at 10+ weeks gestation known to be RhD negative, reported as fetal RhD status
    0632URed blood cell antigen (fetal RhD gene analysis), multiplex polymerase chain reaction (PCR) and next-generation sequencing (NGS) of circulating cell-free DNA (cfDNA), plasma from pregnant individuals known to be RhD negative, reported as detected or not detected
    0633UObstetrics (single-gene noninvasive prenatal test), cell-free DNA (cfDNA), next-generation sequencing (NGS) analysis of 1 or more targets (eg, CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pathogenic variants and to determine fetal inheritance of maternal mutation, using maternal blood sample, algorithm reported as a fetal risk score
    0663UObstetrics (fetal platelet antigen noninvasive prenatal test [NIPT]), cell-free DNA (cfDNA) sequence analysis for detection of fetal presence or absence of 1 or more human platelet antigen (HPA-1a, HPA-1b, HPA-3a, HPA-5b, and others) when performed, reported as maternal/fetal incompatibility
    81422Fetal chromosomal microdeletion(s) genomic sequence analysis (e.g., DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood
    81479Unlisted molecular pathology procedure

    Provider Documentation and Coverage Rules

    Documentation Required

    Medical Necessity Documentation Required

    The patient's medical record must fully support the medical necessity of the requested services. Documentation may be required to assess whether clinical coverage criteria are met, but it does not guarantee coverage.

    • Include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.
    • Keep supporting documentation legible and maintained in the patient's medical record.
    • Make documentation available upon request.
    Billing Rule

    Code Listing Does Not Guarantee Coverage

    Procedure and diagnosis code listings are provided for reference only and may not be all inclusive. Listing a code does not establish that the service is covered or non-covered, create a right to reimbursement, or guarantee claim payment; benefit coverage is determined by applicable federal, state, contractual, and legal requirements.

    Policy Background

    This policy addresses DNA-based noninvasive prenatal testing using cell-free fetal DNA in maternal blood. Testing includes evaluation related to fetal aneuploidy and fetal antigen status. Medical-necessity criteria for DNA-based noninvasive prenatal tests of fetal aneuploidy are established in the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual.

    Policy Summary
    PayerColorado Rocky Mountain Health Plans
    PolicyCell-Free Fetal DNA Testing (for Kansas Only)
    Policy CodePolicy CS085KS.05
    Change TypeRevised
    Effective DateNov 1, 2026
    Next Review DateNot specified
    Key ActionMaintain legible medical record documentation supporting medical necessity, including relevant history, physical examination, and pertinent diagnostic results.
    SourceLink
    On This Page
    Coverage CriteriaCovered IndicationsApplicable CodesProvider Documentation and Coverage RulesPolicy Background
    • Other policies and guidelines may apply.
    • CPT 0488U is listed for reference as fetal DNA in maternal blood obstetrics (fetal antigen noninvasive prenatal test), using cell-free DNA sequence analysis to detect the presence or absence of one or more specified fetal antigens in alloimmunized pregnancies.
    Note

    FDA Status Alone Is Insufficient

    FDA approval or clearance alone is not a basis for coverage. The FDA information in this policy is provided for informational purposes only; coverage remains subject to applicable benefit requirements and coverage criteria.

    • Laboratories that perform DNA-based tests are regulated by the FDA under the Clinical Laboratory Improvement Amendments (CLIA).
    • FDA resources include information on CLIA and nucleic acid-based tests cleared or approved by the FDA Center for Devices and Radiological Health.