CurrentCommunity Health Plan WashingtonPolicy N/A

V1.2025 Concert Genetic Testing: Preimplantation Genetic Testing (PDF)

Policy Summary

PayerCommunity Health Plan Washington

PolicyV1.2025 Concert Genetic Testing: Preimplantation Genetic Testing (PDF)

Policy CodePolicy N/A

Change TypeAdministrative/coding updates

Effective Date

Next Review Date

Key ActionOffer diagnostic confirmation via CVS or amniocentesis after PGT-M or PGT-SR and provide genetic counseling to patients considering IVF/PGT.

SourceLink

POLICY UPDATE CHANGES

Updated title to reflect V1.2025; updated example test in Policy Reference Table and fixed PLA code in criteria.

3PGT types addressed (PGT-A, PGT-M, PGT-SR)

mixedCoverage determinations (some medically necessary, some investigational)

multipleExample CPT/PLA codes listed

Coverage Summary

Defines medical necessity and investigational determinations for preimplantation genetic testing used with in vitro fertilization, including PGT-A (aneuploidy), PGT-M (monogenic disorders), and PGT-SR (structural rearrangements), with example CPT/PLA codes and associated indications. PGT-M and PGT-SR may be considered medically necessary in specified situations described in the criteria, while PGT-A is considered investigational per this policy.

Medical-Necessity Criteria

Preimplantation Genetic Testing for Monogenic Disorders (PGT-M)

Medically necessary criteria and investigational exclusions

ALL of the following

ONE of
- Both biological parents are known carriers for the same autosomal recessive disorder.
- 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.
Preimplantation genetic testing for monogenic disorders (PGT-M) (0396U, 89290, 89291, 81479) is considered investigational for all other indications.

Preimplantation Genetic Testing for Structural Rearrangements (PGT-SR)

Medically necessary criteria and investigational exclusions

ALL of the following

ONE of
- The embryo is at an elevated risk of a genetic disorder because one biological parent has a chromosomal rearrangement.
Preimplantation genetic testing for structural rearrangements (PGT-SR) (81228, 81229, 81479, 89290, 89291) is considered investigational for all other indications.

Preimplantation Genetic Testing for Aneuploidy (PGT-A)

Covered status and investigational determination

Preimplantation genetic testing for aneuploidy (PGT-A) (81229, 81479, 89290, 89291, 0254U) is considered investigational.

Coding (example codes cited)

PGT-A Common CPT/PLA Codes (examples)mixed

81229	Chromosome analysis; whole genome (e.g., microarray) (example for PGT-A)
81479	Unlisted molecular pathology procedure (used as example for PGT-A)
89290	Embryo biopsy
89291	Embryo culture and transfer related (example)
0254U	PLA code example (SMART PGT-A)

PGT-M Common CPT/PLA Codes (examples)mixed

0396U	PLA code example (Spectrum PGT-M / Natera)
89290	Embryo biopsy
89291	Embryo biopsy related
81479	Unlisted molecular pathology procedure (used as example)

PGT-SR Common CPT/PLA Codes (examples)mixed

81228	Chromosome analysis; targeted (example for PGT-SR)
81229	Chromosome analysis; whole genome (example for PGT-SR)
81479	Unlisted molecular pathology procedure
89290	Embryo biopsy
89291	Embryo biopsy related

Common ICD-10 Codes (examples)ICD-10

N97.0	Female infertility associated with anovulation (example used in document)
N97.9	Female infertility, unspecified
Z31	Encounter for fertility testing and counseling
Z14.8	Genetic carrier status (example)

Provider Actions

Documentation Required

Offer diagnostic confirmation after PGT-M or PGT-SR

All patients who undergo PGT-M or PGT-SR should be offered diagnostic testing via chorionic villus sampling (CVS) or amniocentesis for confirmation of results.

Documentation Required

Offer diagnostic testing/screening after PGT-A

All patients who undergo PGT-A should be offered traditional diagnostic testing or screening for aneuploidy in accordance with recommendations for all pregnant patients.

Documentation Required

Genetic counseling recommended

Genetic counseling is highly encouraged and should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods, such as a genetic counselor, medical geneticist, or advanced practice practitioner specializing in genetics, prior to or during IVF/PGT.

Background & Evidence

Preimplantation genetic testing examines biopsied embryo cells during IVF to detect monogenic disorders, structural chromosomal rearrangements, or aneuploidy. PGT-M and PGT-SR are targeted tests to prevent transmission of known familial variants or detect parental chromosomal rearrangements and may be medically necessary when embryos are at elevated risk for those specific conditions. PGT-A is an untargeted screen for chromosomal aneuploidy; this policy considers PGT-A investigational.

Definitions: PGT-A — Preimplantation genetic testing for aneuploidy; used to screen for chromosomal aneuploidy in conjunction with IVF. PGT-M — Preimplantation genetic testing for monogenic disorders; targeted testing for single-gene disorders. PGT-SR — Preimplantation genetic testing for structural rearrangements; used to detect structural chromosomal abnormalities such as translocations.

Source	Summary
ACOG Committee Opinion No. 799 (2020; reaffirmed 2023)	States clinical utility is firmly established for PGT-M and PGT-SR, while the best use of PGT-A remains to be determined; recommends offering confirmation with CVS or amniocentesis for PGT-M and PGT-SR.
ASRM PGT-A opinion (2018) and related ASRM guidance	Concludes insufficient evidence to recommend routine use of blastocyst biopsy with aneuploidy testing in all infertile patients and calls for larger prospective studies; PGT-A not endorsed for all IVF cases.
Concert policy Overview and Criteria (this document)	Defines PGT-M and PGT-SR as targeted tests to detect single-gene disorders or structural chromosomal rearrangements and PGT-A as an untargeted screening for aneuploidy; specifies PGT-A is considered investigational and lists medical necessity criteria for PGT-M and PGT-SR.
Coding / Example tests and codes (Policy Reference Table)	Provides example CPT/PLA codes and example lab tests for PGT-A (e.g., 81229, 81479, 89290, 89291, 0254U; SMART PGT-A, Spectrum/Natera) and for PGT-M and PGT-SR (e.g., 0396U, 81228), noting codes are examples for navigation only.

Policy Summary

PayerCommunity Health Plan Washington

PolicyV1.2025 Concert Genetic Testing: Preimplantation Genetic Testing (PDF)

Policy CodePolicy N/A

Change TypeAdministrative/coding updates

Effective Date

Next Review Date

Key ActionOffer diagnostic confirmation via CVS or amniocentesis after PGT-M or PGT-SR and provide genetic counseling to patients considering IVF/PGT.

SourceLink

On This Page

OpenPayer

V1.2025 Concert Genetic Testing: Preimplantation Genetic Testing (PDF)

Coverage Summary

Medical-Necessity Criteria

Coding (example codes cited)

Provider Actions

Background & Evidence

Revision History