CurrentUnitedHealthcarePolicy CSNCT0559.09

Chromosome Microarray Testing (Non-Oncology Conditions) (for North Carolina Only)

UnitedHealthcare Community Plan Medical Policy (North Carolina only) defining medical necessity and noncoverage for chromosome microarray testing (aCGH and/or SNP array) for non-oncology indications, with recommended pre-test genetic counseling and lists of applicable procedure and diagnosis codes.

Policy Summary

PayerUnitedHealthcare

PolicyChromosome Microarray Testing (Non-Oncology Conditions) (for North Carolina Only)

Policy CodePolicy CSNCT0559.09

Change TypeICD-10 code updates; archival of prior version

Effective DateJan 1, 2026

Next Review Date

Key ActionProvide comprehensive pre-test and post-test genetic counseling and obtain informed consent addressing VUS, non-paternity, consanguinity, and adult-onset findings.

SourceLink

POLICY UPDATE CHANGES

Updated list of applicable ICD-10 diagnosis codes to reflect annual edits.

Archived previous policy version CSNCT0559.08.

5Listed medically necessary indications

manyApplicable diagnosis codes listed

4ICD-10 codes added

2ICD-10 codes removed

Overall CNV detection rate (selected cohorts)

Coverage Summary

UnitedHealthcare Community Plan Medical Policy (North Carolina only) Chromosome Microarray Testing (CMA) for non-oncology conditions (Policy CSNCT0559.09) defines medically necessary and not medically necessary uses of array comparative genomic hybridization (aCGH) and SNP array for constitutional testing. This policy is CURRENT and effective January 1, 2026, applies only to North Carolina, and emphasizes recommended pre-test genetic counseling and lists applicable procedure and diagnosis codes.

Policy metadata

policy_numberCSNCT0559.09

effective_dateJanuary 1, 2026

next_review

statusCURRENT

scope_summaryUnitedHealthcare Community Plan Medical Policy (North Carolina only) defining medical necessity and noncoverage for chromosome microarray testing (aCGH and/or SNP array) for non-oncology indications, with recommended pre-test genetic counseling and lists of applicable procedure and diagnosis codes.

State applicabilityNorth Carolina

Chromosome microarray analysis (CMA), including aCGH and SNP array, detects copy number variations (CNVs) such as deletions and duplications across the genome with greater resolution than karyotype or FISH for many prenatal and pediatric indications. CMA analyzes multiple DNA sequences to identify deletions and duplications genome-wide or targeted to known regions; prenatal diagnostic use requires invasive sampling (e.g., amniocentesis or CVS). Limitations include detection of variants of uncertain significance (VUS), potential false positives requiring confirmatory testing, and inability to detect certain abnormalities such as balanced rearrangements where no net gain or loss of chromosomal material.

Medical-Necessity Criteria

Medically Necessary (Proven) Indications

Chromosome microarray testing using aCGH and/or SNP array is proven and medically necessary for the following:

One of the following

Prenatal/fetal situations
- Intrauterine Fetal Demise or Stillbirth
- Testing the products of conception following pregnancy loss
- Individuals undergoing invasive prenatal testing (i.e., amniocentesis, chorionic villus sampling, or fetal tissue sampling)
Clinical indications

Provider Actions and Requirements

Documentation Required

Pre-test genetic counseling recommended

Pre-test genetic counseling is strongly recommended to inform persons being tested about the advantages and limitations of CMA as applied to their unique situation.

Documentation Required

Obtain informed consent and genetic counseling

Providers must ensure comprehensive pretest and posttest genetic counseling by trained personnel and obtain informed consent that addresses potential variants of uncertain significance (VUS), non-paternity, consanguinity, and adult-onset findings.

Coding

Covered / Reference Procedure CodesCPT

0156U	Copy number (e.g., intellectual disability, dysmorphology), sequence analysis.
0209U	Cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes, and areas of homozygosity for chromosomal abnormalities.
81228	Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number variants, comparative genomic hybridization [CGH] microarray analysis.
81229	Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants, comparative genomic hybridization (CGH) microarray analysis.
81349	Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and loss-of-heterozygosity variants, low-pass sequencing analysis.
81479	Unlisted molecular pathology procedure

HCPCS / State-specific codeHCPCS

S3870

Comparative genomic hybridization (CGH) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability

Diagnosis Codes (ICD-10) referenced as applicableICD-10

F70	Mild intellectual disabilities
F71	Moderate intellectual disabilities
F72	Severe intellectual disabilities
F73	Profound intellectual disabilities
F78.A1	SYNGAP1-related intellectual disability
F78.A9	Other genetic related intellectual disability
F79	Unspecified intellectual disabilities
F80.0	Phonological disorder
F80.1	Expressive language disorder
F80.2	Mixed receptive-expressive language disorder

1–10 of 195

1/20

Applicable ICD-10 diagnosis codes (updated)ICD-10

Q89.89
Q99.89
QA0.0159
QA0.8
Q89.8	REMOVED
Q99.8	REMOVED

Background and Evidence Summary

CMA is a proven diagnostic tool with utility as a first-line test in many settings: prenatal evaluation of fetuses (including stillbirth, products of conception, and invasive prenatal testing), and postnatal evaluation of individuals with neurodevelopmental concerns (DD/GDD, ID, ASD) or multiple congenital anomalies not attributable to a well-delineated genetic syndrome. CMA detects CNVs that may be missed by karyotype and has higher success on nonviable tissue, but findings can include VUS that require parental testing for interpretation; false positives may necessitate additional testing, and CMA cannot detect balanced rearrangements or some other cytogenetic abnormalities.

Citation	Key finding / value
Lu et al. (2024) fetal CHD diagnostic yield
CMA diagnostic yield 15.3% vs karyotype 8.3%; higher yield in CHD with extracardiac anomalies (33.1% vs 9.9%)
Ye et al. (2024) SNP-array in CHD
Non-isolated CHD had highest overall chromosome abnormality frequency (42.6% vs 14.1% isolated)
Peng et al. (2023) POC meta-analysis
Diagnostic yields in products of conception: chromosomal abnormalities 49.9%; pCNVs 2.5%; genomic disorders/syndromic pCNVs 0.8%
Wang et al. (2023) CHD meta-analysis
Pooled proportion overall chromosome abnormalities 23%; aneuploidies 19%; 22q11 deletion 2%; other CNVs 4%; isolated CHD 16% vs non-isolated CHD 37%
Srebniak et al. 2017 meta-analysis
Clinically significant CNV in 1/119 for AMA/anxiety referrals; overall combined risk >1/180 for significant cytogenetic abnormality when combining CNV and karyotype risks
Sheidley et al. 2022 systematic review
Overall diagnostic yield across genetic tests in epilepsy 17%; CMA yield 9%, genome sequencing 48%, exome 24%, multigene panels 19%
McCormack et al. 2016 cohort
28% had a deletion or duplication; CMA informative in 95% of early pregnancy loss cases vs 67% for karyotyping (Pauta meta-analysis)

Glossary (compact): Developmental Delay — used for children <5 years with delayed milestones; Intellectual Disability — diagnosed before age 18 with below-average intellectual function and impaired daily living skills; Intrauterine Fetal Demise or Stillbirth — fetal death at or after 20 weeks' gestation; Prenatal Diagnosis — laboratory testing of fetal DNA/chromosomes before birth; Well‑Delineated Genetic Syndrome — recognizable collection of traits associated with a specific disease (e.g., Down, Turner, Williams); CMA — chromosomal microarray analysis (aCGH and SNP array) for detection of CNVs; CNV — copy number variant (deletion or duplication); VUS — variant of uncertain significance.

Thresholds and Guideline Notes

Thresholds and notable numeric criteria

Use trigger for CMA in FGROffer CMA for unexplained isolated FGR <32 weeks or when FGR with structural anomalies/polyhydramnios (SMFM guidance)

Professional societies require comprehensive pre-test and post-test genetic counseling by providers with genetics expertise and informed consent prior to CMA. Counseling must cover the test's benefits and limitations and explicitly discuss the possibility of VUS, incidental findings such as non-paternity, consanguinity, and potential detection of adult-onset disease. Parental testing is recommended when a VUS is identified to help assess de novo versus inherited status and clarify clinical significance.

Revision History

01/01/2026code_updateLatest

Updated list of applicable ICD-10 diagnosis codes to reflect annual edits: added Q89.89, Q99.89, QA0.0159, and QA0.8; removed Q89.8 and Q99.8.

01/01/2026archivalLatest

Archived previous policy version CSNCT0559.08.

Policy Summary

PayerUnitedHealthcare

PolicyChromosome Microarray Testing (Non-Oncology Conditions) (for North Carolina Only)

Policy CodePolicy CSNCT0559.09

Change TypeICD-10 code updates; archival of prior version

Effective DateJan 1, 2026

Next Review Date

Key ActionProvide comprehensive pre-test and post-test genetic counseling and obtain informed consent addressing VUS, non-paternity, consanguinity, and adult-onset findings.

SourceLink

On This Page

Autism spectrum disorder (ASD)

Isolated severe congenital heart disease

Multiple anomalies that are not specific to a Well-Delineated Genetic Syndrome and cannot be identified by a clinical evaluation alone

Developmental Delay/Intellectual Disability where a specific syndrome is not suspected

Evaluation of biological parent or sibling of a fetus or child with an abnormal or equivocal finding on chromosome microarray testing results

Not Medically Necessary / Unproven

Chromosome microarray testing using aCGH or SNP array is unproven and not medically necessary for all other populations and conditions due to insufficient evidence of efficacy.

Any population or indication not listed in the medically necessary criteria

Indications supported by guidelines and evidence (summary of covered clinical scenarios)

CMA is recommended or considered first-line in the following scenarios according to cited professional societies and evidence:

ANY of the following

Individuals (postnatal) with developmental delay (DD), global developmental delay (GDD), intellectual disability (ID) or autism spectrum disorder (ASD) — CMA as first-tier test
Supported by ACMG, AAP, CCMG and guideline evidence
Individuals (postnatal) with multiple congenital anomalies not specific to a well-delineated genetic syndrome — CMA as first-tier test
Supported by ACMG/ISCA and systematic reviews
Prenatal cases with fetal structural abnormalities detected on ultrasound — prenatal CMA recommended when invasive prenatal diagnosis is performed; CMA may replace karyotype
ACOG/SMFM and ACMG guidance
Stillbirth/intrauterine fetal death when further cytogenetic analysis is desired — CMA preferred due to higher success rate on nonviable tissue and greater detection of CNVs
ACOG/SMFM consensus
Fetuses with abnormal noninvasive prenatal screening (NIPS) results or small copy number changes reported on NIPS — CMA on CVS or amniocentesis may be used for confirmatory diagnosis or reflex to normal karyotype
ACMG practice resource
Pregnant women with fetal growth restriction (FGR) when fetal malformation, polyhydramnios, or both are present, or unexplained isolated FGR <32 weeks — offer CMA
SMFM and SOGC/CCMG recommendations
Children with epilepsy/early-life epilepsies — CMA listed among commonly used genetic tests; diagnostic yield lower than sequencing but may be considered
AAP and Sheidley systematic review
Neonates/children with congenital heart defects (CHD) and additional anomalies — CMA may detect pathogenic CNVs associated with CHD
Meta-analyses and cohort studies show increased yield in non-isolated CHD
Children with idiopathic short stature plus dysmorphic features, DD/ID — CMA may identify recurrent pathogenic CNVs
Pediatric studies demonstrated recurrent pCNVs in this population

Situations where CMA is of limited value or not recommended

Guidance and evidence noting limited utility in certain contexts:

ANY of the following

First trimester pregnancy loss evaluation — evidence limited; use of CMA not recommended as first-line for early pregnancy losses (SMFM 2016)
When a diagnosis of a disorder or syndrome is readily apparent by clinical evaluation alone — CMA not medically necessary (AAN model coverage policy)

Pre-test/post-test requirements and counseling

Professional society recommendations regarding counseling and consent:

Comprehensive pretest and posttest genetic counseling by a provider with genetics expertise is essential; informed consent should include discussion of VUS, non-paternity, consanguinity, and adult-onset disease

ACOG/SMFM and ACMG guidance

Parental testing should be considered when a variant of uncertain significance (VUS) is identified to determine de novo vs inherited status

ACMG technical standards and policy recommendations

Documentation Required

Consider parental testing for VUS interpretation

When CMA identifies a variant of uncertain significance, parental testing is recommended to help determine inheritance and clinical significance.

Prior Authorization

Use in prenatal diagnostic setting when invasive testing is performed

CMA may be performed on chorionic villus sampling (CVS) or amniocentesis for confirmatory diagnosis of abnormal NIPS or when invasive prenatal diagnosis is indicated for fetal structural anomalies; ordering should follow local plan preauthorization rules.

Prior Authorization

State-specific coverage applicability

This policy only applies to the state of North Carolina; providers must follow state and contractual requirements for benefit coverage and reimbursement.

Documentation Required

Reference federal/state/contractual requirements

When deciding coverage, reference federal, state, or contractual benefit plan requirements as they may differ from the standard policy; in the event of conflict, those requirements govern.

Billing Rule

Policy version archived

Archived previous policy version CSNCT0559.08 per revision history (01/01/2026).