CurrentUnitedHealthcarePolicy CS085ID.D

Cell-Free Fetal DNA Testing (for Idaho Only)

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This policy governs cell-free fetal DNA testing coverage for UnitedHealthcare Community Plan members in Idaho, including Idaho Medicaid Plus plans. Medical necessity and coverage criteria are determined by the Idaho Medicaid Provider Handbook and applicable federal, state, or contractual requirements.

Policy Summary

PayerUnitedHealthcare

PolicyCell-Free Fetal DNA Testing (for Idaho Only)

Policy CodePolicy CS085ID.D

Change TypePolicy revision

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionMaintain legible medical record documentation supporting medical necessity and make it available upon request.

SourceLink

POLICY UPDATE CHANGES

CPT codes 0632U and 0633U were added to the applicable code list.

CPT codes 0632U and 0633U are identified as not being on the State of Idaho Medicaid Fee Schedule and therefore may not be covered.

Idaho onlyGeographic application

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CurrentUnitedHealthcarePolicy CS085ID.D

Cell-Free Fetal DNA Testing (for Idaho Only)

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Policy Summary

PayerUnitedHealthcare

PolicyCell-Free Fetal DNA Testing (for Idaho Only)

Policy CodePolicy CS085ID.D

Change TypePolicy revision

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionMaintain legible medical record documentation supporting medical necessity and make it available upon request.

SourceLink

POLICY UPDATE CHANGES

CPT codes 0632U and 0633U were added to the applicable code list.

CPT codes 0632U and 0633U are identified as not being on the State of Idaho Medicaid Fee Schedule and therefore may not be covered.

Idaho onlyGeographic application

Medical Necessity and Coverage Rules

Medical necessity criteria

For medical necessity clinical coverage criteria for genetic testing, refer to the Idaho Medicaid Provider Handbook, Provider Guidelines, Laboratory Services: Genetic Testing.

External Idaho Medicaid criteria: The requested genetic testing service must satisfy the applicable medical necessity and coverage criteria in the Idaho Medicaid Provider Handbook, Provider Guidelines, and Laboratory Services: Genetic Testing.

This policy does not reproduce the applicable Idaho Medicaid criteria.

FDA approval or clearance alone is not a basis for coverage. Coverage is determined under applicable Idaho Medicaid requirements.

Codes identified as not being on the State of Idaho Medicaid Fee Schedule may not be covered by the State of Idaho Medicaid Program.

Covered Testing Indications

Covered indications

This policy does not define a specific covered indication for cell-free fetal DNA testing. Coverage is determined under the applicable Idaho Medicaid requirements.

Applicable Idaho Medicaid coverage requirements: The requested fetal antigen or single-gene cell-free DNA testing service must satisfy the applicable medical necessity and coverage criteria in the Idaho Medicaid Provider Handbook, Provider Guidelines, and Laboratory Services: Genetic Testing.

The listed code descriptions do not independently establish coverage.

Applicable Codes and Coding Requirements

Applicable CodesCPT

0488U

fetal DNA in maternal blood Obstetrics (fetal antigen noninvasive prenatal test), cell-free DNA sequence analysis for detection of fetal presence or absence of 1 or more of the Rh, C, c, D, E, Duffy (Fya), or Kell (K) antigen in alloimmunized pregnancies, reported as selected antigen(s) detected or not detected

Applicable CodesCPT

0489U	Obstetrics (single-gene noninvasive prenatal test), cell-free DNA sequence analysis of 1 or more targets (e.g., CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pathogenic variants, and relative mutation-dosage analysis based on molecular counts to determine fetal inheritance of maternal mutation, algorithm reported as a fetal risk score for the condition (e.g., cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia)
0494U	Red blood cell antigen (fetal RhD gene analysis), next-generation sequencing of circulating cell-free DNA (cfDNA) of blood in pregnant individuals known to be RhD negative, reported as positive or negative
0536U	Red blood cell antigen (fetal RhD), PCR analysis of exon 4 of RHD gene and housekeeping control gene GAPDH from whole blood in pregnant individuals at 10+ weeks gestation known to be RhD negative, reported as fetal RhD status
0632U	Red blood cell antigen (fetal RhD gene analysis), multiplex polymerase chain reaction (PCR) and next-generation sequencing (NGS) of circulating cell-free DNA (cfDNA), plasma from pregnant individuals known to be RhD negative, reported as detected or not detected
0633U	Obstetrics (single-gene noninvasive prenatal test), cell-free DNA (cfDNA), next-generation sequencing (NGS) analysis of 1 or more targets (e.g., CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pathogenic variants and to determine fetal inheritance of maternal mutation, using maternal blood sample, algorithm reported as a fetal risk score
81422	Fetal chromosomal microdeletion(s) genomic sequence analysis (e.g., DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood
81479	Unlisted molecular pathology procedure

Codes not on State of Idaho Medicaid Fee ScheduleCPT

0489U	Obstetrics (single-gene noninvasive prenatal test), cell-free DNA sequence analysis of 1 or more targets
0494U	Red blood cell antigen (fetal RhD gene analysis), next-generation sequencing of circulating cell-free DNA
0536U	Red blood cell antigen (fetal RhD), PCR analysis
0632U	Red blood cell antigen (fetal RhD gene analysis), multiplex PCR and NGS of circulating cell-free DNA
0633U	Obstetrics (single-gene noninvasive prenatal test), cfDNA NGS analysis

Gestational age for fetal RhD PCR testing

Applicable testCPT 0536U: Fetal RhD PCR analysis from whole blood in pregnant individuals known to be RhD negative

Minimum gestational age10+ weeks gestation

Reported resultFetal RhD status

Documentation and Coverage Actions

Documentation Required

Medical Necessity Documentation

The patient's medical record must contain documentation that fully supports the medical necessity of the requested services. Documentation should be legible, maintained in the medical record, and made available upon request; it may include relevant medical history, physical examination findings, and pertinent diagnostic test or procedure results. Documentation may be required to assess coverage but does not guarantee coverage.

Maintain legible records supporting medical necessity.
Include relevant history, examination findings, and pertinent diagnostic or procedure results.
Make supporting documentation available upon request.

Denial Risk

Idaho Medicaid Coverage Requirements

Coverage may be denied or unavailable when the applicable Idaho Medicaid medical necessity and coverage requirements are not met. Refer to the Idaho Medicaid Provider Handbook, Provider Guidelines, Laboratory Services: Genetic Testing, for the clinical coverage criteria.

Cell-Free Fetal DNA Testing

Cell-free fetal DNA testing analyzes fetal genetic material circulating in maternal blood. The services addressed by this policy include fetal antigen noninvasive prenatal testing, including fetal RhD and other red blood cell antigens, as well as noninvasive single-gene testing for selected inherited conditions.

Services Not Covered or Not Assured

FDA approval or clearance alone is not a basis for coverage. In addition, CPT codes 0632U and 0633U are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program.