CurrentCommunity Health Plan WashingtonPolicy N/A

V2.2025 Concert Genetic Testing: Preimplantation Genetic Testing

Defines medical necessity criteria for preimplantation genetic testing types—PGT-A (aneuploidy), PGT-M (monogenic disorders), and PGT-SR (structural rearrangements)—including when testing may be considered medically necessary and when evidence does not support use.

Policy Summary

PayerCommunity Health Plan Washington

PolicyV2.2025 Concert Genetic Testing: Preimplantation Genetic Testing

Policy CodePolicy N/A

Change TypeMinor wording and coding updates

Effective DateN/A

Next Review DateN/A

Key ActionGenetic counseling is highly encouraged for patients considering and undergoing IVF and should be performed by an individual with genetics expertise.

SourceLink

POLICY UPDATE CHANGES

Policy language updated to replace 'investigational' with 'Current evidence does not support…' throughout the policy.

PGT-M: updated example test in policy reference table and fixed PLA code in criteria.

3PGT types addressed

ConditionalPGT-M coverage stance

ConditionalPGT-SR coverage stance

Not routinely supportedPGT-A coverage stance

Coverage Summary

Policy on Preimplantation Genetic Testing (PGT-A, PGT-M, PGT-SR) — CURRENT: This policy defines medical necessity criteria for preimplantation genetic testing types: PGT-A (aneuploidy), PGT-M (monogenic disorders), and PGT-SR (structural rearrangements).

Genetic counseling is highly encouraged for patients considering and undergoing IVF and should be performed by an individual with expertise in genetic medicine (e.g., genetic counselor, medical geneticist, or advanced practice practitioner specializing in genetics).

Policy references guidance from major professional societies, including the American Society for Reproductive Medicine (ASRM) and the American College of Obstetricians and Gynecologists (ACOG), regarding appropriate use and clinical utility of PGT modalities.

Policy summary — key values

PGT types addressed3

PGT-M coverage stanceConditional

PGT-SR coverage stanceConditional

PGT-A coverage stanceNot routinely supported

last_review2025-11

effective_date

next_review

Medical-Necessity Criteria

Preimplantation Genetic Testing for Aneuploidy (PGT-A)

Policy statement regarding PGT-A:

ALL of the following

Current evidence does not support preimplantation genetic testing for aneuploidy (PGT-A) for all indications.

Preimplantation Genetic Testing for Monogenic Disorders (PGT-M)

PGT-M may be considered medically necessary when:

ALL of the following

ANY of the following
- Both biological parents are known carriers for the same autosomal recessive disorder.

Provider Actions & Documentation

Documentation Required

Genetic counseling recommended

Genetic counseling is highly encouraged for patients considering and undergoing IVF and should be performed by an individual with experience and expertise in genetic medicine and testing methods (for example, a genetic counselor, medical geneticist, or advanced practice practitioner specializing in genetics).

Documentation Required

Parental carrier status documentation for PGT-M

For PGT-M medical necessity, document that the embryo is at an elevated risk of a genetic disorder because both biological parents are known carriers of the same autosomal recessive disorder, or one biological parent is a known carrier of an autosomal dominant disorder, or one biological parent is a known carrier of an X-linked recessive disorder. Accepted documentation includes records confirming parental carrier status (genetic test reports or clinical genetics documentation).

Coding (examples from policy)

PGT-A common billing codes (examples listed in document)mixed

81229
81479
89290
89291
0254U
N97.0
N97.9
Z31

PGT-M common billing codes (examples listed in document)mixed

81479
89290
89291
0396U
N97.0
N97.9
Z14.8
Z31

PGT-SR common billing codes (examples listed in document)mixed

81228
81229
81479
89290
89291
N97.0
N97.9
Z14.8
Z31

Background & Evidence

This policy addresses the use of embryonic biopsy testing performed as part of in vitro fertilization to detect monogenic disorders (PGT-M), structural chromosomal rearrangements (PGT-SR), and chromosomal aneuploidy (PGT-A).

Genetic counseling is strongly recommended for patients considering and undergoing IVF and PGT, and should be provided by clinicians with genetics expertise.

Recommendations and clinical context reference ASRM and ACOG committee opinions on PGT, which establish that clinical utility is established for PGT-M and PGT-SR while the routine use of PGT-A remains to be determined.

Source	Summary
ASRM opinion on PGT-A	2018 committee opinion concluding insufficient evidence for routine use of PGT-A in all infertile patients; reaffirmed guidance on mosaicism management (2020).
ACOG Committee Opinion No. 799	2020 (reaffirmed 2023) noting clinical utility established for PGT-M and PGT-SR while PGT-A utility remains to be determined.

Definitions:

• PGT-A: Preimplantation genetic testing for aneuploidy used to screen for chromosomal aneuploidy in conjunction with in vitro fertilization (IVF).

• PGT-M: Preimplantation genetic testing for monogenic disorders used to detect a specific single-gene inherited disorder or chromosome rearrangement in conjunction with IVF.

• PGT-SR: Preimplantation genetic testing for structural rearrangements used to detect a chromosome structural rearrangement in conjunction with IVF.

Revision History

2025-11revisionLatest

Minor rewording without clinical significance; replaced 'investigational' policy statements with 'Current evidence does not support…..' throughout policy; policy reference table, rationale, background and coding table updated.

11/24revision

Semi-annual review: Updated title to reflect V1.2025. Preimplantation Genetic Testing for Monogenic Disorders (PGT-M): Updated example test in Policy Reference Table, fixed PLA code in criteria; minor rewording without clinical significance; replaced 'investigational' policy statements with 'Current evidence does not support…..' throughout policy; policy reference table, rationale, background and coding table updated.

11/25

Policy Summary

PayerCommunity Health Plan Washington

PolicyV2.2025 Concert Genetic Testing: Preimplantation Genetic Testing

Policy CodePolicy N/A

Change TypeMinor wording and coding updates

Effective DateN/A

Next Review DateN/A

Key ActionGenetic counseling is highly encouraged for patients considering and undergoing IVF and should be performed by an individual with genetics expertise.

SourceLink

On This Page

One biological parent is a known carrier of an autosomal dominant disorder.

One biological parent is a known carrier of an X-linked recessive disorder.

Exclusion: Current evidence does not support preimplantation genetic testing for monogenic disorders (PGT-M) for all other indications.

Preimplantation Genetic Testing for Structural Rearrangements (PGT-SR)

PGT-SR may be considered medically necessary when:

The embryo is at an elevated risk of a genetic disorder because one biological parent has a chromosomal rearrangement.

Exclusion: Current evidence does not support preimplantation genetic testing for structural rearrangements (PGT-SR) for all other indications.

Documentation Required

Parental chromosomal rearrangement documentation for PGT-SR

For PGT-SR medical necessity, document that the embryo is at an elevated risk because one biological parent has a chromosomal structural rearrangement (for example, a translocation). Documentation may include parental cytogenetic or molecular genetic test reports confirming the chromosomal rearrangement.

Annual review: Minor rewording without clinical significance; replaced 'investigational' policy statements with 'Current evidence does not support…..' throughout policy; policy reference table, rationale, background and coding table updated.

04/24revision

Semi-annual review: Overview and Clinical Considerations consolidated; coding, reference-table, background and references updated. Preimplantation Genetic Testing for Monogenic Disorders (PGT-M): updated example test in policy reference table and fixed PLA code in criteria (reflected in coding table examples).