Currentsierra health and lifePolicy 2026T0597Q

Preimplantation Genetic Testing

Defines medical necessity, covered indications and exclusions for Preimplantation Genetic Testing (PGT) and related services (PGT-M, PGT-SR, and related reproductive procedures) for UnitedHealthcare Commercial and Individual Exchange plans. Describes required ordering, documentation, covered related services, and exclusions (notably PGT-A and long-term embryo storage).

Policy Summary

Payersierra health and life

PolicyPreimplantation Genetic Testing

Policy CodePolicy 2026T0597Q

Change TypeRevised coverage rationaleterminology and reference updates

Effective DateMay 1, 2026

Next Review Date

Key ActionPGT must be ordered by a physician after genetic counseling and documentation of counseling and increased embryo risk/severity should be provided.

SourceLink

POLICY UPDATE CHANGES

Coverage Rationale language revised to state PGT is proven and medically necessary only for PGT-M or PGT-SR using PCR, NGS, or chromosomal microarray.

Replaced reference to 'gender' with 'sex'.

Added reference link to the Medical Policy titled Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions).

Updated Description of Services, Clinical Evidence, and References sections to reflect current information.

2Covered PGT types (PGT-M, PGT-SR)

1Excluded PGT type (PGT-A)

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Max short-term storage (years)

multipleEvidence sources summarized

age-dependentNotable subgroup effect

Coverage Summary

This policy applies to UnitedHealthcare Commercial and Individual Exchange plans and defines medical necessity for Preimplantation Genetic Testing (PGT) and related services.

The policy states that PGT is proven and medically necessary only for PGT-M (monogenic/single-gene defects) and PGT-SR (inherited structural chromosome rearrangements) when performed to prevent conditions that would cause Significant Health Problems or Severe Disability and when ordered by a physician after genetic counseling.

Acceptable testing methods required for covered PGT are polymerase chain reaction (PCR), next-generation sequencing (NGS) (e.g., for chromosomal rearrangements), or chromosomal microarray.

Key exclusions and limitations include that PGT-A (aneuploidy screening) is not a covered PGT indication, PGT-P (polygenic risk / polygenic scores) and other nonindicated uses lack sufficient evidence, and benefits do not cover long-term embryo storage greater than 1 year (short-term storage <1 year is limitedly covered).

Surface thresholds and quick facts

Short-term embryo storageless than 1 year

Long-term storage coverageNot covered for >1 year

PGT types designated as proven/medically necessaryPGT-M and PGT-SR

Specifically excluded PGT typePGT-A (aneuploidy screening) not covered

Age subgroup referenced for potential PGT-A benefit35 to 40 years

Medical-Necessity Criteria

Medically Necessary Coverage for PGT (PGT-M and PGT-SR)

PGT is proven and medically necessary only when ALL of the following are met:

ALL of the following

PGT must be ordered by a physician after genetic counseling
Genetic counseling is strongly recommended prior to PGT; policy note: 'PGT must be ordered after genetic counseling.'
Increased risk due to ONE of
- Each of the intended parents is a carrier of the same autosomal recessive disease
- At least one parent is a carrier of an autosomal dominant, sex-linked, or mitochondrial condition

Not Medically Necessary / Unproven Uses

Not Medically Necessary / Unproven

PGT is unproven and not medically necessary for ALL of the following populations/uses:

ANY of the following

Aneuploidy screening (PGT-A)
Determining sex 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
All other populations and conditions not meeting criteria above due to insufficient evidence of efficacy

Coverage Limitations and Exclusions

Coverage Rationale

Coverage Rationale (as revised)

Policy states PGT is covered only in specific circumstances:

ALL of the following

Preimplantation Genetic Testing (PGT) is proven and medically necessary only for monogenic/single-gene defects (PGT-M) or inherited structural chromosome rearrangements (PGT-SR)
Testing methods must be polymerase chain reaction (PCR), next-generation sequencing (NGS, e.g., for chromosomal rearrangements), or chromosomal microarray
Coverage applies for the listed indications referenced elsewhere in the policy

Material revision: the Coverage Rationale was revised to explicitly limit proven/medically necessary PGT to PGT-M and PGT-SR and to specify acceptable methods as PCR, NGS, or chromosomal microarray.

Other non-material or minor updates include terminology changes (e.g., replacing reference to 'gender' with 'sex'), added supporting links (Whole Exome and Whole Genome Sequencing policy), and updates to Description of Services, Clinical Evidence, and References; previous policy version 2026T0597P was archived.

Evidence Summary & Society Guidance

PGT-A (Aneuploidy Screening) — Not established as universally beneficial

Evidence and guidance indicate limitations and lack of established benefit for routine universal use:

ANY of the following

Multiple RCTs and society guidance indicate PGT-A has not been shown to improve live birth rate (LBR) universally; benefit uncertain and debated (e.g., Yan et al. 2021; Munné et al. 2019)
Some post-hoc analyses suggest possible benefit in select subgroups (e.g., age 35–40) but findings are limited and not definitive
PGT-A may detect mosaicism and aneuploidy but interpretation and clinical management are controversial

PGT-P (Polygenic Risk) — Not appropriate for clinical use

Society guidance and reviews state insufficient evidence and ethical concerns:

Management of Mosaic and Diagnostic Results

Management of Mosaic Results

Society guidance on mosaic embryos and transfer:

ALL of the following

ASRM and PGDIS recommend comprehensive genetic counseling for patients considering transfer of mosaic embryos and for those who conceive after mosaic ET
PGDIS recommends reporting relative percentage/level of mosaicism and considering level/type of mosaicism and embryo morphology when prioritizing transfers
Referral to a pediatric geneticist is recommended for patients whose results indicate abnormal physical or developmental phenotypes

Coding

Primary PGT and related molecular/procedure codes (referenced for PGT benefit)CPT|HCPCS

0254U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score, per embryo tested
0552U	Reproductive medicine (preimplantation genetic assessment), analysis for known genetic disorders from trophectoderm biopsy, linkage analysis of disease-causing locus, and when possible, targeted mutation analysis for known familial variant
0553U	Reproductive medicine, analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, and mitochondrial DNA score, per embryo tested
0554U	Reproductive medicine, analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, mitochondrial DNA score, and embryo quality control, per embryo tested
0555U	Reproductive medicine, analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, ploidy, mitochondrial DNA score, and embryo quality control, per embryo tested
81228	Cytogenomic (genome-wide) analysis; CGH microarray analysis
81229	Cytogenomic analysis; CGH microarray with SNP variants
81349	Cytogenomic analysis; low-pass sequencing analysis
81479	Unlisted molecular pathology procedure
89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique; ≤5 embryos

1–10 of 35

1/4

Codes specifically called out as included in benefit limits (not included in PGT benefit limits)CPT

81228	Cytogenomic (genome-wide) analysis; CGH microarray analysis
81229	Cytogenomic analysis; CGH microarray with SNP variants
81349	Cytogenomic analysis; low-pass sequencing analysis
81479	Unlisted molecular pathology procedure

No procedure or diagnosis codes listed in this document partmixed

No codes listed

Provider Actions & Requirements

Prior Authorization

Order after genetic counseling

PGT must be ordered by a physician after genetic counseling; documentation of genetic counseling may be required for review.

Documentation Required

Demonstrate increased risk and severity

Providers must document that the embryo is at increased risk due to parental carrier status or structural rearrangement and that the condition would result in Significant Health Problems or Severe Disability.

Definitions

PGT-A: Preimplantation Genetic Testing for aneuploidy — testing embryos for whole-chromosome aneuploidy prior to transfer; noted in policy as not established for universal benefit and specifically listed among unproven/not medically necessary uses.

PGT-M: Preimplantation Genetic Testing for monogenic/single-gene defects — testing embryos to prevent single-gene disorders; designated as proven/medically necessary when criteria are met.

PGT-SR: Preimplantation Genetic Testing for chromosomal structural rearrangements — testing embryos from translocation/inversion carriers; designated as proven/medically necessary when criteria are met.

TE biopsy: Trophectoderm (TE) biopsy — sampling cells from the embryo's trophectoderm at the blastocyst stage for genetic testing.

niPGT-A: Noninvasive PGT-A — testing cell-free DNA released into embryo culture media; investigational data cited but routine use not established.

PGD-HLA: Preimplantation genetic diagnosis with HLA typing — PGT to create HLA-matched donors for an affected sibling; considered medically necessary when used to provide bone marrow or blood to treat that sibling.

Significant Health Problems or Severe Disability: defined as a physical or mental impairment that substantially limits one or more major life activities, expected to last ≥12 months or result in death (per Department of Labor/Social Security definition).

Revision History

05/01/2026revisedLatest

Coverage Rationale language revised to state PGT is proven and medically necessary only for PGT-M or PGT-SR using PCR, NGS, or chromosomal microarray.

05/01/2026revised

Replaced reference to 'gender' with 'sex' across policy language.

05/01/2026added

Policy Summary

Payersierra health and life

PolicyPreimplantation Genetic Testing

Policy CodePolicy 2026T0597Q

Change TypeRevised coverage rationaleterminology and reference updates

Effective DateMay 1, 2026

Next Review Date

Key ActionPGT must be ordered by a physician after genetic counseling and documentation of counseling and increased embryo risk/severity should be provided.

SourceLink

On This Page

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)

Significant Health Problems or Severe Disability defined as impairment expected to last ≥12 months or result in death.

ALL of the following

Ovulation induction (or controlled ovarian stimulation)
Egg retrieval, fertilization, and embryo culture
Embryo biopsy
Embryo transfer
Cryopreservation and short-term embryo storage (less than 1 year)

Medically Necessary: HLA typing

Covered when ALL of the following are met:

ALL of the following

PGT performed for human leukocyte antigen (HLA) typing on an embryo
Purpose is for the future child to provide bone marrow or blood to treat an affected sibling

The following are specifically excluded or limited:

ALL of the following

Benefits are not available for long-term storage costs (greater than 1 year)
Benefits are not available for PGT-A

ALL of the following

Clinical utility of PGT-P / preimplantation polygenic risk scores (PRS) for embryo selection is lacking
Professional societies (ACMG, ESHRE, Hayes review) recommend PGT-P not appropriate for clinical use and should be limited to research settings

PGT-M and PGT-SR — Supported use and recommendations

Society guidance supports use when specific conditions are met:

ALL of the following

ACOG and ASRM indicate clinical utility of PGT-M and PGT-SR is established for certain indications
Recommendation for confirmation of PGT-M and PGT-SR results by chorionic villus sampling or amniocentesis should be offered to all patients
Comprehensive genetic counseling is recommended before and after testing and when making ET decisions
PGT-SR is recommended only if the applied technique can detect all expected unbalanced forms of the chromosomal rearrangement
Technique sensitivity for PGT-SR emphasized

Evidence summarized in the policy includes multiple systematic reviews, cohort studies, RCTs, and registry analyses with heterogeneous results across indications and subgroups.

Key studies cited: Mao et al. (2024) meta-analysis on TE biopsy safety and obstetric/neonatal outcomes; Poulton et al. (2025) systematic review of PGT-M (pooled clinical pregnancy ~34% and LBR ~29.7% per cycle with significant heterogeneity and suggestion of higher outcomes when concurrent PGT-A used); the STAR RCT (Munné et al. 2019) found no overall OPR/LBR benefit for universal PGT-A but a subgroup per-ET benefit in ages 35–40; a pilot RCT Beebeejaun et al. (2025) showed no significant difference in LBR but a trend toward higher cumulative LBR with PGT-A; multicenter and cohort data (e.g., Japan Iwasa et al. 2023, SART analyses) show improved per-ET outcomes or age-dependent effects in some settings.

Overall, results are heterogeneous and subgroup-dependent, with some evidence supporting PGT-M and PGT-SR utility for preventing severe inherited disorders, mixed or limited evidence for routine PGT-A benefit, and guidance recommending PGT-P be limited to research.

Billing Rule

Limitations on embryo storage billing

Benefits exclude long-term storage costs greater than 1 year; short-term storage (less than 1 year) is covered when provided under physician supervision.

89342 — Storage (per year); embryo(s): long-term storage (>1 year) excluded

Documentation Required

Counseling on utility of PGT-A

Providers should counsel patients on the uncertain overall benefit of PGT-A and the evidence suggesting potential benefit in individuals of advanced maternal age or poor prognosis; counseling should include discussion of possible reduced miscarriage rates, variable effects on live birth rates, and assay-specific limitations (mosaicism, false positives/negatives).

Documentation Required

Consideration of patient selection

Providers should consider patient age, ovarian reserve, history of recurrent pregnancy loss (RPL) or recurrent implantation failure (RIF), and the number/quality of available embryos when determining whether to offer PGT-A or PGT-SR, as studies show heterogeneous benefits across subgroups.

Documentation Required

Confirmatory diagnostic testing offer

Offer confirmation of PGT-M and PGT-SR results by chorionic villus sampling or amniocentesis to all patients.

Documentation Required

Genetic counseling requirement

Provide comprehensive genetic counseling (pretest and posttest) for patients considering PGT-M, PGT-SR, PGT-A mosaic transfers, and for those conceiving after mosaic ET; counseling should involve experienced PGT genetic counselor and may include condition-specific experts.

Prior Authorization

Coverage limited to specific PGT indications and methods

Coverage applies only for PGT-M and PGT-SR when performed using PCR, NGS, or chromosomal microarray and for the listed policy indications; prior authorization may be required per plan (member-specific benefit documents govern).

Denial Risk

PGT-P and routine PGT-A not covered/unsupported

PGT-P (polygenic/PRS-based embryo selection) is considered not clinically supported for routine clinical use and should be limited to research; routine universal PGT-A lacks established benefit and may not meet medical necessity criteria.

Added reference link to the Medical Policy titled Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions).

05/01/2026updated

Updated Description of Services, Clinical Evidence, and References sections; previous policy version archived (2026T0597P).