CurrentTexas Children's Health PlanPolicy 6188

Noninvasive Prenatal Screening (NIPS or NIPT) Genetic Testing Guidelines

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Prior authorization and medical-necessity review for noninvasive prenatal screening during pregnancy, including eligibility, documentation, coverage limitations, and non-covered uses.

Policy Summary

PayerTexas Children's Health Plan

PolicyNoninvasive Prenatal Screening (NIPS or NIPT) Genetic Testing Guidelines

Policy CodePolicy 6188

Change TypeNo material change

Effective DateJun 27, 2023

Next Review DateN/A

Key ActionSubmit prior authorization documentation, including medical necessity, eligibility criteria, genetic counseling, and a baseline ultrasound, before requesting NIPS/NIPT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7Qualifying medical-necessity indications

10+ weeksMinimum gestational age

10–55Member age range

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CurrentTexas Children's Health PlanPolicy 6188

Noninvasive Prenatal Screening (NIPS or NIPT) Genetic Testing Guidelines

Customize your policy alerts

Sign up for texaschildrenshealthplan Policy 6188 alerts

Get alerted when Policy 6188 changes without checking for updates manually.

Monitor payer policy activity

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Prior authorization and medical-necessity review for noninvasive prenatal screening during pregnancy, including eligibility, documentation, coverage limitations, and non-covered uses.

Policy Summary

PayerTexas Children's Health Plan

PolicyNoninvasive Prenatal Screening (NIPS or NIPT) Genetic Testing Guidelines

Policy CodePolicy 6188

Change TypeNo material change

Effective DateJun 27, 2023

Next Review DateN/A

Key ActionSubmit prior authorization documentation, including medical necessity, eligibility criteria, genetic counseling, and a baseline ultrasound, before requesting NIPS/NIPT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7Qualifying medical-necessity indications

10+ weeksMinimum gestational age

10–55Member age range

T13, T18, T21Eligible trisomies

81599Not reimbursed code

NIPS Coverage Criteria and Limitations

Medically Necessary NIPS Eligibility

Noninvasive prenatal screening (NIPS/NIPT) is medically necessary when ALL of the following requirements are met:

ALL of the following

Member has a current single-gestation pregnancy.
Gestational age is 10 weeks or greater.>= 10 weeks
ONE of the following clinical criteria is met
- Maternal age is 35 years or older at the expected date of delivery.>= 35 years at expected date of delivery
- Fetal ultrasound findings indicate an increased risk of aneuploidy.
- There was a previous pregnancy with aneuploidy.
- Fetal ultrasound shows structural anomalies associated with aneuploidy, and the member is not yet ready for an invasive diagnostic test.
- A known balanced Robertsonian translocation is present in a parent or the parent of the partner.
- Abnormal first-trimester screen
  - Sequential screen
  - Integrated screen
  - Quadruple or Penta screen
- Clinical risk is verified by the TCHP Medical Director or Physician Reviewer.

NIPT Procedure-Code Limitations

NIPT procedure codes are subject to all of the following coverage and authorization limitations:

ALL of the following

Procedure code 81420 or 81507 is billed for a female member ages 10 through 55 years.Age 10–55 years
The NIPT is limited to once per pregnancy; additional tests will not be authorized.
Procedure code 81420 is denied when billed during the same pregnancy as procedure code 81507 by any provider.

NIPS is not a benefit when performed as part of a routine prenatal laboratory assessment.

NIPS is not a benefit when performed without informed patient choice and pre- and post-screen genetic counseling from a qualified professional.

NIPS is not a benefit for women who do not meet the eligibility criteria outlined in Section 5.

NIPS is not a benefit for women with multiple gestations, including twins, triplets, or other multiple pregnancies.

NIPS is not a benefit for screening of chromosomal microdeletion syndromes.

NIPS is not a benefit for screening of trisomies other than trisomy 13, trisomy 18, or trisomy 21.

NIPS is not a benefit when performed for sex determination, paternity determination, or other non-medical reasons.

NIPS is not reimbursed when billed with procedure code 81599.

In the case of a no-call or inconclusive result, further diagnostic testing is strongly recommended. Repeating the NIPT is not covered.

NIPS is not medically necessary under this guideline when the member does not have a current single-gestation pregnancy at 10 weeks gestation or greater.

Qualifying Medical-Necessity Indications

Maternal Age Indication

Covered when the following indication is documented in a qualifying pregnancy:

Advanced maternal age: The member has a current single-gestation pregnancy at 10 weeks gestation or greater, and maternal age is 35 years or older at the expected date of delivery.Single gestation; at least 10 weeks; age 35 or older at expected date of delivery

Fetal Ultrasound Findings Indicating Increased Aneuploidy Risk

Covered when the following indication is documented:

Increased aneuploidy risk on ultrasound: Fetal ultrasound findings indicate an increased risk of aneuploidy.

Previous Pregnancy With Aneuploidy

Covered when the following indication is documented:

Procedure Codes and Coverage Parameters

Restricted NIPT procedure codesCPT

81420	NIPT procedure code restricted to female members ages 10 through 55 and limited to once per pregnancy
81507	NIPT procedure code restricted to female members ages 10 through 55 and limited to once per pregnancy

Not reimbursedCPTNot Covered

81599

NIPS is not reimbursed with procedure code 81599

Gestational Age

RequirementCurrent single-gestation pregnancy at 10 weeks gestation or greater

Member Age

Eligible member ageFemale members ages 10 through 55 years of age

Testing Frequency

Testing limitLimited to once per pregnancy; additional tests will not be authorized

Authorization, Documentation, and Billing Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for all noninvasive prenatal testing requests. Requests are received by the TCHP Utilization Management Department during normal business hours through online submission, fax, phone, or mail.

Submit the request through an available TCHP Utilization Management channel: online, fax, phone, or mail.

Prior Authorization

Out-of-Network Authorization

Requests conducted by out-of-network providers are treated as out-of-network requests and must comply with applicable out-of-network authorization guidelines.

Documentation Required

Medical Necessity and Eligibility Documentation

Required Clinical Documentation

Prior authorization documentation must include a baseline ultrasound documenting the number of fetuses, gestational age, and viability. Documentation should also identify the qualifying eligibility basis, such as an abnormal sequential, integrated, quadruple, or penta screen, when applicable.

Non-Covered Uses

The following uses are not covered: screening for chromosomal microdeletion syndromes; screening for trisomies other than T13, T18, or T21; and NIPS for sex determination, paternity determination, or non-medical reasons. NIPS for multiple gestations and other uses that do not meet the stated criteria are also not a benefit.

About Noninvasive Prenatal Screening

Noninvasive prenatal screening (NIPS/NIPT) uses a maternal blood sample to assess the risk of selected fetal chromosomal aneuploidies. It is a screening test, not a diagnostic test; counseling must explain that a negative result does not ensure an unaffected pregnancy.

Policy Summary

PayerTexas Children's Health Plan

PolicyNoninvasive Prenatal Screening (NIPS or NIPT) Genetic Testing Guidelines

Policy CodePolicy 6188

Change TypeNo material change

Effective DateJun 27, 2023

Next Review DateN/A

Key ActionSubmit prior authorization documentation, including medical necessity, eligibility criteria, genetic counseling, and a baseline ultrasound, before requesting NIPS/NIPT.

SourceLink

On This Page

Prior pregnancy with aneuploidy: The member had a previous pregnancy with aneuploidy.

Structural Fetal Anomalies Associated With Aneuploidy

Covered when both parts of the following indication are documented:

Structural fetal anomalies: Fetal ultrasound shows structural anomalies associated with aneuploidy, and the member is not yet ready for an invasive diagnostic test.

Both the ultrasound finding and lack of readiness for invasive diagnostic testing are required.

Balanced Robertsonian Translocation

Covered when the following indication is documented:

Balanced Robertsonian translocation: A known balanced Robertsonian translocation is present in a parent or the parent of the partner.

Abnormal First-Trimester Screening

Covered when the following indication is documented:

Abnormal first-trimester screening: An abnormal first-trimester screen is documented, including a sequential screen, integrated screen, quadruple screen, or penta screen.

At least one listed screening result must be abnormal.

Clinical Risk Verified by TCHP Review

Covered when the following indication is documented:

Clinically verified risk: Clinical risk is verified by a TCHP Medical Director or Physician Reviewer.

The rendering provider must submit documentation supporting medical necessity and confirming that the member meets the NIPS criteria. Authorization is based on medical necessity and is not a guarantee of benefits or eligibility; benefit limitations and exclusions still apply.

Describe the medical necessity of the requested procedure.
Document that the member meets the applicable testing criteria.
Document a current single-gestation pregnancy at 10 weeks or greater and at least one qualifying indication, including maternal age 35 or older at expected delivery, increased aneuploidy risk on ultrasound, prior pregnancy with aneuploidy, qualifying fetal structural anomalies when the member is not ready for invasive diagnostic testing, a known balanced Robertsonian translocation in a parent or the parent of the partner, an abnormal first-trimester screen, or clinical risk verified by a TCHP Medical Director or Physician Reviewer.

Documentation Required

Genetic Counseling Documentation

The medical record must document qualified, nondirective genetic counseling both before and after screening. Counseling must be provided by a trained genetic counselor, genetics nurse specialist, maternal-fetal medicine specialist, or another medical provider with genetic-counseling expertise who is not affiliated with the genetic screening laboratory.

Document discussion of the benefits, risks, and limitations of advanced screening.
Document the nature, inheritance, potential outcomes, and implications of aneuploidy screening and each possible aneuploidy result.
Document that the member understands that a negative screen does not ensure an unaffected pregnancy and was supported in making an informed medical and personal decision.

Documentation Required

Baseline Ultrasound Required

Submit a baseline ultrasound documenting the number of fetuses, gestational age, and viability.

The medical record must establish a current single-gestation pregnancy for the applicable criteria.

Denial Risk

Non-Covered Indications and Uses

NIPS is not a benefit for routine prenatal laboratory assessment or for uses outside the established medical-necessity criteria and covered scope.

Not covered when performed without informed patient choice and qualified pre- and post-screen genetic counseling.
Not covered for women who do not meet the applicable criteria.
Not covered for multiple gestations, including twins or triplets.
Not covered for chromosomal microdeletion screening or screening for trisomies other than T13, T18, or T21.
Not covered for sex determination, paternity determination, or non-medical reasons.
NIPS billed with procedure code 81599 is not reimbursed.

Denial Risk

Repeat Testing Limitation

Only one NIPT is allowed per pregnancy. Additional testing will not be authorized, including repeat NIPT after a no-call or inconclusive result; further diagnostic testing is strongly recommended in those circumstances.

A no-call or inconclusive result does not support repeating NIPT.

Billing Rule

Age and Frequency Restrictions

Procedure codes 81420 and 81507 are restricted to female members ages 10 through 55 years and are limited to once per pregnancy.

Additional tests will not be authorized.

Billing Rule

Mutually Exclusive Code Billing

Procedure code 81420 will be denied when billed during the same pregnancy as procedure code 81507 by any provider.

Do not bill 81420 and 81507 for the same pregnancy.

Denial Risk

Non-Reimbursable Code

NIPS is not reimbursed when billed with procedure code 81599.

Procedure code: 81599

Denial Risk

Medical Director Review

Requests that do not meet the established criteria are referred to a TCHP Medical Director or Physician Reviewer for review, and the Denial Policy will be followed.

Clinical risk may be verified by a TCHP Medical Director or Physician Reviewer.

Documentation Required

Provider Action: Genetic Counseling

Arrange and document qualified, nondirective genetic counseling before and after NIPS. The counselor must be appropriately qualified and independent of the genetic screening laboratory.

Qualified personnel include a trained genetic counselor, genetics nurse specialist, maternal-fetal medicine specialist, or another medical provider with genetic-counseling expertise.
Ensure the member receives information on screening benefits, risks, limitations, possible results, and the implications of a negative screen.

Prior Authorization

Provider Action: Submit Authorization Documentation

The provider rendering direct care to the member must submit the prior authorization documentation to TCHP Utilization Management.

Submit the medical-necessity description, eligibility documentation, genetic-counseling documentation, and baseline ultrasound.
Submission channels are online, fax, phone, or mail during normal business hours.
Providers must comply with state and federal requirements; noncompliance may result in retrospective audit and financial recoupment.