CurrentUnitedHealthcarePolicy CS085KS.02

Cell-Free Fetal DNA Testing (for Kansas Only)

Defines UnitedHealthcare Community Plan coverage guidance for DNA-based noninvasive prenatal testing (cell-free fetal DNA) specific to Kansas providers and members. Applies to services provided under the Kansas Medical Assistance Program as referenced.

Policy Summary

PayerUnitedHealthcare

PolicyCell-Free Fetal DNA Testing (for Kansas Only)

Policy CodePolicy CS085KS.02

Change TypeApplicable codes updated

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionConsult the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for medical necessity criteria before ordering testing.

SourceLink

POLICY UPDATE CHANGES

Applicable Codes were updated and CPT codes 0327U, 81420, and 81507 were removed.

2025-09-01effective date

State-specificpolicy applicability

≥7 codesprocedure codes referenced

Kansas manualcoverage source

Coverage Criteria

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Medical necessity (referenced)

Covered when medical necessity criteria from the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual are met.

Referenced criteria: Medical necessity clinical coverage criteria for DNA-based noninvasive prenatal tests of fetal aneuploidy are defined in the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual.

Provider must consult the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for the detailed medical necessity criteria and any state-specific requirements.

Listing a procedure or diagnosis code in this policy is for reference only and does not imply coverage. Benefit coverage and reimbursement are determined by applicable federal, state, or contractual requirements and laws; this policy alone does not establish coverage and services may be excluded under those requirements.

This policy does not enumerate specific conditions that are "not medically necessary." Determinations that a service is not medically necessary are made according to the member’s applicable benefit plan and the referenced Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual; providers should consult those sources when making medical necessity decisions.

Covered Indications

DNA-based noninvasive prenatal tests of fetal aneuploidy

Medical necessity criteria for DNA-based noninvasive prenatal tests of fetal aneuploidy are defined by the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual.

Referenced criteria: DNA-based noninvasive prenatal tests of fetal aneuploidy (cell-free fetal DNA) are covered only when the medical necessity criteria in the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual are met.

See the Kansas manual (reference below) for eligibility, clinical indications, timing, and any documentation or prior authorization requirements.

Coding and Billing

Applicable PLA/other codes referencedmixed

0060U	Twin zygosity, genomic targeted sequence analysis of chromosome 2, using circulating cell-free fetal DNA in maternal blood.
0488U	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.
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.

Additional molecular CPT codesCPT

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

inv-06: Gestational age for PCR RhD testing — 10+ weeks gestation

Gestational age requirementSpecimens for PCR-based fetal RhD testing (CPT PLA 0536U) are performed at 10+ weeks gestation.

Applicable test methodPCR analysis of exon 4 of the RHD gene with housekeeping control gene GAPDH from whole blood.

Patient populationPregnant individuals known to be RhD negative.

Reported resultFetal RhD status (reported as fetal RhD status).

Code referencedPLA code 0536U corresponds to this PCR RhD test at 10+ weeks gestation.

Definitions

inv-12: Cell-free fetal DNA testing — definition of DNA-based noninvasive prenatal tests performed on maternal plasma

DefinitionDNA-based noninvasive prenatal tests performed on circulating cell-free fetal DNA in maternal blood, including assays for fetal aneuploidy, red blood cell antigens (e.g., RhD), and single-gene noninvasive prenatal tests.

Examples of test typesAneuploidy cfDNA assays, single-gene NIPT (e.g., CFTR, SMN1, HBB, HBA1, HBA2), and fetal red blood cell antigen testing (e.g., RhD).

Specimen sourceCirculating cell-free fetal DNA in maternal blood (plasma/whole blood depending on assay).

Typical reportsResults are reported as presence/absence (e.g., antigen detected/not detected), fetal risk scores, or fetal RhD status depending on assay type.

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Benefit Plan Governance

Prior authorization requirements are governed by the member's federal, state, or contractual benefit plan and are not specified in this document. Providers must check the applicable benefit plan terms before ordering services.

Prior authorization governed by benefit plan — confirm requirements with the member's federal, state, or contractual plan before providing services.
In the event of a conflict between this policy and the member's federal, state, or contractual benefit plan, the federal, state, or contractual requirements govern.

Step Therapy

No step therapy requirements are specified in this medical policy. Providers should verify whether the member's benefit plan imposes any step therapy rules.

No step therapy requirements specified in this policy document.

Note

Code Listings and Coverage

Listing a code in a policy does not imply the service is a covered benefit. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws; inclusion of a code does not guarantee reimbursement or payment.

Listing of codes in the policy is for reference only and is not a coverage determination.

Documentation Required

Provider Responsibility to Verify Benefit Plan Rules

Providers must reference the member's federal, state, or contractual benefit plan for coverage, prior authorization, and other administrative requirements. If there is any conflict between this policy and those benefit plan requirements, the federal, state, or contractual requirements control. UnitedHealthcare may modify policies; always confirm plan-level rules before rendering services.

Providers must reference federal, state, or contractual requirements for benefit plan coverage; in the event of conflict, follow the member's plan/manual.
Confirm prior authorization, pre- or post-test counseling, ordering clinician qualifications, and other administrative requirements with the applicable benefit plan.

Documentation Required

Genetic Counseling Requirements

This policy does not specify explicit pre- or post-test genetic counseling requirements. Providers should follow the Kansas Medical Assistance Program manual and applicable federal, state, or contractual benefit plan rules for any counseling requirements.

No explicit pre- or post-test genetic counseling requirements stated in this policy; follow the Kansas Medical Assistance Program manual and applicable benefit plan rules.

Documentation Required

Ordering Clinician Requirements

This policy does not specify particular ordering clinician qualifications. Providers should follow the Kansas Medical Assistance Program manual and any applicable federal, state, or contractual benefit plan requirements regarding who may order services.

No specific ordering clinician requirements stated in this policy; follow the Kansas Medical Assistance Program manual and applicable benefit plan requirements.

OpenPayer

Cell-Free Fetal DNA Testing (for Kansas Only)

Coverage Criteria

Covered Indications

Coding and Billing

Definitions

Eligibility Requirements

Provider Actions and Requirements

Not Covered / Exclusions

Background