CurrentColorado Rocky Mountain Health PlansPolicy CS160OH.E

Preimplantation Genetic Testing and Related Services (for Ohio Only)

Coverage policy for Preimplantation Genetic Testing (PGT) and related reproductive services for members of Colorado Rocky Mountain Health Plans in the state of Ohio only. Describes circumstances when PGT is medically necessary, conditions considered, testing modalities, and applicable procedure codes.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPreimplantation Genetic Testing and Related Services (for Ohio Only)

Policy CodePolicy CS160OH.E

Change TypeCodes added

Effective DateSep 1, 2025

Next Review Date

Key ActionOrder PGT only after documented genetic counseling and follow applicable federal, state, or contractual coverage requirements when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Added CPT codes 0552U, 0553U, 0554U, and 0555U to Applicable Codes.

4new CPT U-codes added

Medical Necessity Criteria for Preimplantation Genetic Testing (PGT)

Medically Necessary - PGT-M and PGT-SR (proven and medically necessary)

PGT (using PCR, NGS, or CMA) is proven and medically necessary when ALL of the following are met:

ALL of the following

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The increased risk is due to one of:
- Both intended parents are carriers of the same autosomal recessive disease
- At least one parent is a carrier of an autosomal dominant, sex-linked, or mitochondrial condition
- At least one parent is a carrier of a structural chromosome rearrangement
The medical condition being prevented must result in Significant Health Problems or Severe Disability and be caused by a single gene (PGT-M) or structural changes of a parent's chromosome (PGT-SR)

Medically Necessary - HLA typing by PGT

PGT is proven and medically necessary when used for HLA typing in order for the future child to provide hematopoietic (bone marrow or blood) transplant to treat an affected sibling.

ALL of the following

PGT performed for HLA typing on an embryo with the intent that the child will be an HLA match donor for an affected sibling

Not Medically Necessary / Unproven

PGT (CMA, PCR, or NGS) is unproven and not medically necessary for all other populations and conditions due to insufficient evidence, including but not limited to:

ANY of the following

Aneuploidy screening (PGT-A)
Determining gender when the embryo is not at risk for a sex-linked disorder
Predicting risk of polygenic disorders (PGT-P) and/or embryo selection based on polygenic scores (ESPS)

Applicable Procedure and Related Codes

Direct PGT molecular/cyto tests and related proprietary codesCPT/PLA/HCPCS/mixed

0254U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score in euploid embryos, per embryo tested.
0552U	Reproductive medicine (preimplantation genetic assessment), analysis for known genetic disorders from trophectoderm biopsy, linkage analysis and targeted mutation analysis when possible.
0553U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes from embryonic trophectoderm for structural rearrangements, aneuploidy, and mitochondrial DNA score, per embryo tested.
0554U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes from trophectoderm biopsy for aneuploidy, ploidy, mitochondrial DNA score, and embryo quality control, per embryo tested.
0555U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes from embryonic trophectoderm for structural rearrangements, aneuploidy, ploidy, mitochondrial DNA score, and embryo quality control, per embryo tested.
81479	Unlisted molecular pathology procedure (described in policy text as 'Unlisted molecular pathology procedure').
89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); <= 5 embryos.
89291	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); > 5 embryos.

Related ART/ancillary procedure CPT/Codes (identified with *)CPT/HCPCS/mixed

58970	Follicle puncture for oocyte retrieval, any method
58974	Embryo transfer, intrauterine
76948	Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation
89250	Culture of oocyte(s)/embryo(s), less than 4 days
89251	Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture
89253	Assisted embryo hatching, microtechniques
89254	Oocyte identification from follicular fluid
89255	Preparation of embryo for transfer
89257	Sperm identification from aspiration (other than seminal fluid)
89258	Cryopreservation; embryo(s)

1–10 of 24

1/3

Added CPT (U-codes) in 09/01/2025 revisionCPT

0552U
0553U
0554U
0555U

Actions, Documentation, and Denial Risks for Providers

Documentation Required

Genetic counseling requirement

Genetic counseling requirement PGT must be ordered after genetic counseling; counseling should document the advantages and limitations of the test as applied to the patient's situation.

Denial Risk

Not covered indications

Not covered indications PGT for aneuploidy screening (PGT-A), elective sex determination (when not at risk for sex-linked disorder), and PGT-P/ESPS (polygenic risk/embryo selection by polygenic scores) are considered unproven and not medically necessary and may be denied.

Documentation Required

Reference applicable federal/state/contractual requirements

Reference applicable federal/state/contractual requirements When deciding coverage, providers must reference federal, state (Ohio Administrative Code) or contractual requirements for benefit plan coverage as these may govern over the standard policy in case of conflict.

Documentation Required

Use InterQual and applicable UnitedHealthcare criteria

Use InterQual and applicable UnitedHealthcare criteria UnitedHealthcare uses InterQual for primary medical/surgical criteria; if InterQual lacks applicable criteria, UnitedHealthcare may use its Medical Policies, Coverage Determination Guidelines, and Utilization Review Guidelines approved by the Ohio Department for Medicaid Services to inform coverage decisions.

Clinical and Technical Background

Preimplantation Genetic Testing (PGT) evaluates DNA from oocytes (including polar bodies) or embryos (cleavage stage or blastocyst) to detect genetic abnormalities before embryo transfer. PGT is performed for three primary indications: PGT-M (testing for known monogenic or single-gene disorders), PGT-SR (testing for structural chromosomal rearrangements), and PGT-A (screening for aneuploidy, formerly called PGS).

Laboratory techniques used for PGT include targeted methods such as polymerase chain reaction (PCR), genome-wide and targeted sequencing approaches including next-generation sequencing (NGS), and cytogenomic assays such as chromosomal microarray (CMA) or array comparative genomic hybridization. These modalities may be applied to material from polar bodies, blastomeres, or trophectoderm biopsies depending on the clinical protocol and assay.

Evidence of clinical benefit varies by indication and by the testing method. PGT-M and PGT-SR performed with validated molecular or cytogenomic methods are recognized indications when embryos are at increased risk for a significant single-gene disorder or a parental structural rearrangement. In contrast, the clinical utility of PGT-A is mixed: some studies and meta-analyses suggest benefit in selected populations (for example, individuals with advanced maternal age or certain recurrent pregnancy loss cohorts), while other high-quality trials and reviews show inconsistent or uncertain improvement in live birth or cumulative live birth rates. Given evolving technology and the 09/01/2025 policy update adding new procedure codes, genetic counseling is required prior to testing to document the test’s advantages and limitations for the individual patient.

Key Definitions

Definitions

PGT-APreimplantation Genetic Testing for aneuploidy (formerly PGS) — screening embryos for abnormal chromosome number.

PGT-MPreimplantation Genetic Testing for monogenic/single gene defects (formerly PGD).

PGT-SRPreimplantation Genetic Testing for structural rearrangements (formerly PGD for chromosomal rearrangements).

Significant Health Problems or Severe DisabilityA disability or impairment that is physical or mental and substantially limits one or more major life activities, expected to last at least 12 months or result in death.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPreimplantation Genetic Testing and Related Services (for Ohio Only)

Policy CodePolicy CS160OH.E

Change TypeCodes added

Effective DateSep 1, 2025

Next Review Date

Key ActionOrder PGT only after documented genetic counseling and follow applicable federal, state, or contractual coverage requirements when requesting coverage.

SourceLink

On This Page

OpenPayer

Preimplantation Genetic Testing and Related Services (for Ohio Only)

Medical Necessity Criteria for Preimplantation Genetic Testing (PGT)

Applicable Procedure and Related Codes

Actions, Documentation, and Denial Risks for Providers

Clinical and Technical Background

Key Definitions

Material Policy Changes

Preimplantation Genetic Testing and Related Services (for Ohio Only)

Medical Necessity Criteria for Preimplantation Genetic Testing (PGT)

Applicable Procedure and Related Codes

Actions, Documentation, and Denial Risks for Providers

Clinical and Technical Background

Key Definitions

Policies to Read With This Document

Material Policy Changes