CurrentMass General Brigham Health PlanPolicy 044

Preimplantation Genetic Testing (PGT)

Defines medical necessity, coverage, and authorization requirements for preimplantation genetic testing (PGT-M and PGT-SR) and states that PGT-A is not covered; applies to Mass General Brigham Health Plan members and relevant plan variations.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPreimplantation Genetic Testing (PGT)

Policy CodePolicy 044

Change TypeAnnual and ad hoc updatesauthorization clarified

Effective DateJanuary 2026

Next Review Date

Key ActionObtain initial authorization from Mass General Brigham UM and, if approved, secure a second authorization from EviCore.

SourceLink

POLICY UPDATE CHANGES

Updated prior authorization table and added variation for OneCare and SCO members; fixed code disclaimer.

Added MassHealth variation and clarified Medicare variation; added one biological parent having an unbalanced translocation to conditions eligible for PGT-SR; added Retinoblastoma to list of single gene autosomal dominant disorders.

Authorization requirements clarified to require two authorizations: first from Mass General Brigham UM and second from EviCore for approved cases.

PGT‑M & PGT‑SR covered; PGT‑A not coveredcoverage stance summary

Two‑stepauthorization workflow

044policy identifier

Medicare/MassHealth/OneCare/SCO

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plan-specific variations

Coverage criteria for Preimplantation Genetic Testing (PGT)

PGT-SR (structural rearrangements)

Covered when ALL of the following are met:

PGT-SR coverage: PGT-SR is covered to test for unbalanced chromosome rearrangements when one of the genetic parents is known to have an unbalanced translocation, a balanced reciprocal or Robertsonian translocation, or a microdeletion/duplication or other structural chromosomal abnormality associated with the birth of an affected child

Laboratory documentation may be required

PGT-M (monogenic disorders)

Covered when ANY of the following genetic-parent scenarios apply (AND documentation and counseling requirements are met):

PGT-M coverage: Both genetic parents are known carriers of a single-gene autosomal recessive disorder (examples listed), OR one genetic parent is a known carrier and they have an affected child, OR one genetic parent is a known carrier of a single-gene autosomal dominant disorder (examples listed), OR the genetic female parent is a known carrier of a single-gene X-linked recessive disorder (examples listed)

Associated assisted reproductive services (e.g., IVF, ICSI) are covered when medically necessary; specialist/PCP must provide clinical documentation and counseling; two-step authorization required

PGT is covered when the clinical coverage criteria for PGT-M or PGT-SR are met. PGT used solely as an adjunct to infertility services for members who do not meet those clinical criteria is excluded and may be denied. Providers should not request PGT for fertility‑adjunct purposes when the member does not satisfy the specific genetic indications outlined under covered PGT‑M or PGT‑SR.

Mass General Brigham Health Plan does not cover PGT for several non‑indicated uses, including PGT-A (aneuploidy screening), carrier-status screening of embryos, HLA typing to create a future donor, translocations that always produce abnormal gametes, gender selection without a documented X‑linked disorder, selection for non‑medical traits, or selection against predisposition when no single causative defect is known. These exclusions also apply where members are not expected to be fertile due to age‑related decline or certain sterilization statuses; such situations must meet other policy provisions (for example, sterilization reversal criteria) before PGT would be considered.

Members with ovaries who are 40 years of age or older must demonstrate adequate ovarian reserve to be eligible for PGT. Acceptable evidence includes menstrual history plus one of the specified laboratory or imaging assessments performed within the stated timeframes.

Acceptable tests and thresholds include: a recent Clomiphene Citrate Challenge Test (CCCT) meeting the policy parameters (FSH ≤ 15 mIU/mL and estradiol ≤ 80 pg/mL as outlined in the CCCT criteria), an AMH level > 1.0 ng/mL or an antral follicle count > 6 within the past 12 months combined with an FSH < 15 mIU/mL within the past 6 months. Documentation of these results must be provided with the prior authorization request.

Preimplantation genetic testing for aneuploidy (PGT-A) is not covered. This exclusion applies to PGT‑A performed for routine aneuploidy screening, as well as PGT‑A in the contexts of recurrent miscarriage, repeated implantation failure during IVF, or advanced maternal age. Requests for PGT‑A may be denied.

Coding and billing

Informational CPT CodesCPT

89290	Biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos.
89291	Biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); greater than 5 embryos.

Provider actions, authorization, and documentation requirements

Prior Authorization

Prior Authorization Required

Two-step prior authorization is required for Preimplantation Genetic Testing (PGT). The specialist or ordering provider must obtain an initial authorization from Mass General Brigham Health Plan utilization management (UM). If Mass General Brigham UM approval is obtained, a second authorization must be obtained from EviCore for approved cases.

Initial authorization: Mass General Brigham Health Plan UM
Second authorization: EviCore (required only if first authorization approved)

Documentation Required

Required Clinical Documentation

The specialist and/or primary care provider are responsible for providing all necessary clinical information for authorization requests. Required documentation includes medical history of the patient and partner (or child, where appropriate), relevant genetic testing/laboratory results, documentation of the specific genetic disorder or chromosomal rearrangement being tested for, and counseling notes confirming that the member/couple were advised about alternative testing options (for example, amniocentesis or chorionic villous sampling), potential risks of PGT (embryo arrest, diagnostic uncertainty, unknown long-term effects), and the possibility that traditional prenatal diagnostic testing may still be recommended after successful PGT and pregnancy.

Background on preimplantation genetic testing

Preimplantation genetic testing (PGT) is performed on embryos created using assisted reproductive technology (for example, in vitro fertilization) to detect genetic or chromosomal abnormalities prior to embryo transfer. PGT‑M targets single‑gene (monogenic) disorders, and PGT‑SR targets structural chromosomal rearrangements; cells (typically 5–10) are removed from a blastocyst for analysis. When used for appropriate indications, PGT‑M and PGT‑SR can prevent transmission of a known familial genetic disorder and reduce the risk of having an affected child or experiencing pregnancy loss.

While PGT can inform embryo selection and improve outcomes for specific genetic indications, broad use of PGT for aneuploidy screening (PGT‑A) remains unsupported by the evidence and is excluded from coverage. Providers should ensure that PGT requests are limited to the covered indications and accompanied by the required documentation and genetic counseling.

Definitions

Preimplantation Genetic Testing — definition

DefinitionA test performed on an embryo created using assisted reproductive technology (e.g., IVF); five to ten cells are removed from a developing blastocyst for genetic testing of a specific condition.

ContextPerformed after fertilization and blastocyst development; used to detect single-gene disorders, structural rearrangements, or other targeted genetic conditions.

Sample sizeTypically 5–10 cells are biopsied from the blastocyst for analysis.

Autosomal Dominant — definition

DefinitionAn inheritance pattern in which only one copy of an abnormal gene from one parent is sufficient to cause the disorder; one parent may often have the disease.

Implication for offspringEach child of an affected parent has a risk of inheriting the disorder depending on penetrance and expressivity.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPreimplantation Genetic Testing (PGT)

Policy CodePolicy 044

Change TypeAnnual and ad hoc updatesauthorization clarified

Effective DateJanuary 2026

Next Review Date

Key ActionObtain initial authorization from Mass General Brigham UM and, if approved, secure a second authorization from EviCore.

SourceLink

On This Page

Medical history of patient and partner (or child, where appropriate)
Laboratory/genetic test documentation (e.g., parental karyotype, mutation analysis)
Documentation of counseling regarding alternatives, risks, and potential need for prenatal diagnostic testing

Denial Risk

Exclusion — PGT as Adjunct to Infertility

PGT used as an adjunct to infertility services is excluded when the member does not meet the clinical coverage criteria for Preimplantation Genetic Testing. Requests for PGT in this context may be denied.

Exclusion applies when PGT is requested solely as an adjunct to infertility services and clinical coverage criteria are not met

Denial Risk

PGT-A Not Covered

Preimplantation genetic testing for aneuploidy screening (PGT-A) is not covered. PGT-A requests, including when sought for recurrent miscarriage, repeated implantation failure during IVF, or advanced maternal age, are excluded and may be denied.

PGT-A (aneuploidy screening) is not covered under this policy
Includes PGT-A for recurrent miscarriage, repeated failed implantation, or advanced maternal age

Note

Not specified / Provider Note

Not specified: If additional provider actions or documentation requirements are needed beyond those listed (for example, program-specific forms or laboratory submission procedures), providers should follow directions provided by Mass General Brigham Health Plan UM and EviCore at the time of authorization.

Follow any payer- or vendor-specific submission instructions provided during the authorization process

Typical family patternDisorder may be seen in successive generations with affected individuals in each generation.

Autosomal Recessive — definition

DefinitionA disorder that requires two mutated copies of a gene (one from each parent) in each cell for the disease or trait to develop; parents are typically unaffected carriers.

Carrier statusParents usually each carry a single copy of the mutated gene and are clinically unaffected.

Risk to offspringWhen both parents are carriers, each child has an increased risk (often 25%) of being affected depending on the specific condition.

X-linked Recessive / Dominant — definition

X-linked patterns — generalMutations in genes on the X chromosome; inheritance and affectedness differ between males and females.

X-linked dominantCaused by mutations on the X chromosome; females are more frequently affected than males and transmission risks differ between mothers and fathers.

X-linked recessiveCaused by mutations on the X chromosome; males are more frequently affected than females; affected males are common in families while affected females are rare; fathers cannot pass X-linked traits to their sons.