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    v1.0.28
    OpenPayerPolicy UpdatesReproductive Health & FertilityIndependent Health Preimplantation Genetic Testing…
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    CurrentIndependent HealthPolicy M20210312010

    Preimplantation Genetic Testing Policy

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    Defines Independent Health's medical necessity criteria for preimplantation genetic diagnostic testing as an adjunct to in vitro fertilization (IVF), lists populations and product lines where covered or excluded, and specifies prior authorization and documentation responsibilities.

    Policy Summary
    PayerIndependent Health
    PolicyPreimplantation Genetic Testing Policy
    Policy CodePolicy M20210312010
    Change TypeFormatting revision (10/1/2025)
    Effective DateMay 1, 2021
    Last ReviewOct 1, 2025
    Next Review Date
    Key ActionSecure prior authorization and submit all relevant member-level clinical information to the rendering laboratory before claims; claims without prior authorization will be denied and members must not be billed.
    SourceLink
    POLICY UPDATE CHANGES

    10/1/2025 entry: Revised-Formatting Only.

    1Primary Covered Indication Set

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    3
    Product Lines Excluding Coverage
    1Prior Authorization Required

    Coverage Summary

    Defines Independent Health's medical necessity criteria for preimplantation genetic diagnostic testing as an adjunct to in vitro fertilization (IVF); coverage stance: mixed; subject: Preimplantation Genetic Testing (PGD/PGT). Effective date: 2021-05-01; Last review: 2025-10-01.

    Key Policy Items
    Policy NumberM20210312010
    Effective Date5/1/2021
    Last Review10/1/2025
    Coverage StanceMixed — medically necessary for specific genetic indications; investigational/not covered for other uses and certain product lines
    Primary Covered Indication Count1
    Major Product Lines Excluding Coverage3 (Medicare Advantage; State Medicaid products; Small & Individual Groups/FEHB)
    Prior Authorization RequirementYes — prior authorization required; ordering/rendering lab responsible

    Medical-Necessity Criteria

    Clinical Indications - Medically Necessary (Covered)

    Preimplantation genetic diagnostic testing may be considered medically necessary and a covered benefit when ALL of the following criteria are met:

    ALL of the following

    • ONE or more of

      • Both parents are known carriers of a recessive genetic condition, and the specific gene mutation has been identified in each parent
      • One parent is affected by or known to be a carrier of a dominant condition, and the specific gene mutation has been identified
      • The female contributing the egg is known to be a carrier of an X-linked condition and the specific gene mutation has been identified

    Provider Actions

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for preimplantation genetic testing. The ordering/rendering laboratory is responsible for securing prior authorization for medically necessary molecular diagnostic testing; claims received without prior authorization will deny to the rendering laboratory.

    • The ordering/rendering laboratory is responsible for securing prior authorization for medically necessary molecular diagnostic testing; claims lacking prior authorization will deny to the rendering laboratory.
    Documentation Required

    Clinical Information Submission

    The ordering/referring physician must provide the rendering laboratory with all relevant member-level clinical information to support the prior authorization request for molecular diagnostic testing.

    • Ordering/referring physician must submit all relevant member-level clinical information to the rendering laboratory to support the prior authorization request.

    Coding

    Related molecular diagnostic testing (no explicit codes listed)mixed
    No codes listed

    Background & Definitions

    Preimplantation genetic diagnosis (PGD/PGT) involves biopsy of one or two cells from embryos during IVF to perform molecular analysis and detect specific genetic diseases, allowing transfer of embryos without the identified genetic condition. Independent Health evaluated peer-reviewed literature to develop its medical necessity criteria. This policy clarifies that coverage of preimplantation genetic testing does not imply coverage of IVF where IVF is not otherwise provided.

    TermDefinition
    In vitro fertilization (IVF)Procedure to treat infertility where ovaries are stimulated, oocytes are aspirated and fertilized in the laboratory and embryos transferred to the uterus.
    Preimplantation genetic testingTesting performed on an embryo for either diagnostic (PGD) or screening (PGS/PGT-A) purposes prior to implantation.
    Preimplantation diagnostic testing (PGD)Testing performed on cells from the developing embryo prior to implantation when one or both parents have a known genetic abnormality.
    Preimplantation screening testing (PGS/PGT-A)Screening an embryo for aneuploidy when both parents are chromosomally normal.

    References include: ACOG Committee Opinion Number 799 (March 2020; reaffirmed 2023) cited as a reference.

    Not Covered / Investigational

    Product-line specific exclusions: For State product members (MediSource, MediSource Connect, Essential Plan/New York Medicaid), preimplantation genetic diagnosis associated with IVF is not covered. For Medicare Advantage members, preimplantation genetic diagnostic testing is not covered. For Small and Individual Groups or FEHB Commercial members, preimplantation genetic diagnostic testing is not covered. Investigational statements: Preimplantation genetic diagnostic testing as an adjunct to IVF is investigational in situations other than the specified medically necessary indications, and preimplantation genetic screening (PGT-A/PGS) as an adjunct to IVF is investigational in all situations. These exclusions and investigational determinations are specified in the 'Not Medically Necessary / Investigational' criteria group above.

    Evidence & Guidance

    Evidence and references: ACOG Committee Opinion Number 799 (March 2020; reaffirmed 2023) is cited. Additional referenced guidance includes ASRM/SART practice committee opinions on preimplantation genetic testing and PGT-A, and peer-reviewed literature and reviews (examples listed in the policy's references).

    Revision History

    2025-10-01revisionLatest

    Revised-Formatting Only.

    2024-10-01review

    Reviewed.

    2024-01-01revision

    Revised.

    Policy Summary
    PayerIndependent Health
    PolicyPreimplantation Genetic Testing Policy
    Policy CodePolicy M20210312010
    Change TypeFormatting revision (10/1/2025)
    Effective DateMay 1, 2021
    Last ReviewOct 1, 2025
    Next Review Date
    Key ActionSecure prior authorization and submit all relevant member-level clinical information to the rendering laboratory before claims; claims without prior authorization will be denied and members must not be billed.
    SourceLink
    On This Page
    Coverage SummaryMedical-Necessity CriteriaProvider ActionsCodingBackground & DefinitionsNot Covered / InvestigationalEvidence & GuidanceRevision History
    One or both parents are carriers of a structural chromosome rearrangement (e.g., translocation or inversion)
  1. One or both parents have a known chromosome microdeletion (e.g., 22q11 deletion DiGeorge syndrome, 7q11.23 deletion - Williams syndrome)
  2. The genetic condition is associated with potentially severe disability or has a lethal natural history

    3. Not Medically Necessary / Investigational (Not Covered)

    Preimplantation genetic testing is considered investigational and not covered in situations other than the specified covered indications:

    ANY of the following

    • Preimplantation genetic diagnostic testing as an adjunct to in vitro fertilization (IVF) is considered investigational in patients or couples who are undergoing IVF in all situations other than those specified above
    • Preimplantation genetic screening (PGT-A/PGS) as an adjunct to IVF is considered investigational in all situations
    • For State product members; preimplantation genetic diagnosis associated with in vitro fertilization services is not covered
    • For Medicare Advantage members; preimplantation genetic diagnostic testing is not covered
    • For Small and Individual Groups or FEHB Commercial members; preimplantation genetic diagnostic testing is not covered
    Denial Risk

    Claim Denial and Member Billing Protection

    Claims for molecular diagnostic testing received without prior authorization will be denied to the rendering laboratory; Independent Health members shall not be billed for such claims.

    • Claims for molecular diagnostic testing received without prior authorization will be denied to the rendering laboratory and members shall not be billed.
    2023-10-01review

    Reviewed.

    2022-10-01revision

    Revised.

    2022-05-01review

    Reviewed.

    2021-05-01effective

    Policy effective date.