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    OpenPayerPolicy UpdatesGenetic & Molecular TestingUnitedHealthcare cfDNA Coverage Update | OpenPayer
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    CurrentUnitedHealthcarePolicy CS085ID.C

    Cell-Free Fetal DNA Testing (for Idaho Only)

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    Defines UnitedHealthcare Community Plan coverage guidance for cell-free fetal DNA testing for members in Idaho, including Idaho Medicaid Plus plans; references Idaho Medicaid Provider Handbook for clinical criteria.

    Policy Summary
    PayerUnitedHealthcare
    PolicyCell-Free Fetal DNA Testing (for Idaho Only)
    Policy CodePolicy CS085ID.C
    Change TypeDocumentation expandedcoding clarification
    Effective DateAug 1, 2026
    Last ReviewAug 1, 2026
    Next Review Date
    Key ActionFollow Idaho Medicaid Provider Handbook for medical necessity criteria and ensure medical record documentation fully supports requested services.
    SourceLink
    POLICY UPDATE CHANGES

    Medical Records Documentation Used for Reviews section was expanded to specify documentation that must support medical necessity and may be requested.

    Notation added that specific CPT codes (0060U, 0488U, 0489U, 0494U, 0536U, 81422) are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid.

    Idaho-onlystate application
    0060U, 0488U, 0489U, 0494U, 0536U, 81422codes potentially not covered
    Idaho Medicaid Handbook

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    clinical criteria source
    Addeddocumentation expectations

    Coverage Criteria (Idaho Medicaid Delegation)

    Medical necessity (delegated to Idaho Medicaid Provider Handbook)

    Covered when clinical criteria in the Idaho Medicaid Provider Handbook are met.

    Idaho Medicaid clinical criteria: Coverage is determined by meeting the medical necessity clinical coverage criteria described in the Idaho Medicaid Provider Handbook, Provider Guidelines, Laboratory Services: Genetic Testing.

    This policy defers to and does not duplicate the Idaho Medicaid Provider Handbook criteria.

    Some CPT codes listed in this policy are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid. Providers should consult the Idaho Medicaid Provider Handbook, General Information and Requirements for Providers: Non-Covered and Excluded Services for specific guidance on coverage and billing for these codes.

    This policy delegates determinations of medical necessity to the Idaho Medicaid Provider Handbook. Coverage for cell-free fetal DNA testing is based on meeting the medical necessity clinical coverage criteria described in the Idaho Medicaid Provider Handbook, Provider Guidelines, Laboratory Services: Genetic Testing; this policy does not itself enumerate the clinical criteria used to determine medical necessity for Idaho members.

    Coding and Procedure Codes

    Applicable CPT / molecular procedure codes (reference)CPT
    0488Ufetal 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
    0489UObstetrics (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)
    0494URed 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
    0536URed 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
    81422Fetal chromosomal microdeletion(s) genomic sequence analysis (e.g., DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood
    81479Unlisted molecular pathology procedure
    0060UListed in policy notes as a CPT code not on the Idaho Medicaid Fee Schedule (specific description not provided in document)
    Gestational age for RHD PCR test
    Gestational age threshold>= 10 weeks for PCR RHD test (CPT 0536U)
    Applicable test codeCPT 0536U — Red blood cell antigen (fetal RhD), PCR analysis of exon 4 of RHD gene and housekeeping control gene GAPDH from whole blood
    Reportable resultReported as fetal RhD status (positive or negative)

    The following CPT codes in the Applicable Codes section are marked with an asterisk to indicate they are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid: 0060U, 0488U, 0489U, 0494U, 0536U, 81422. Refer to the Idaho Medicaid Provider Handbook, General Information and Requirements for Providers: Non-Covered and Excluded Services for additional details.

    Provider Actions, Authorization, and Documentation

    Prior Authorization

    Prior authorization: follow Idaho Medicaid Provider Handbook

    Refer to the Idaho Medicaid Provider Handbook for medical necessity clinical coverage criteria and any prior authorization requirements; this policy does not itself enumerate prior authorization rules or criteria.

    • Follow Idaho Medicaid Provider Handbook, Provider Guidelines, Laboratory Services: Genetic Testing for clinical criteria and authorization rules.
    Note

    Follow Idaho Medicaid Provider Handbook for unspecified provider actions

    The policy does not specify an additional distinct provider-action in this section; follow Idaho Medicaid Provider Handbook and contractual requirements for any ordering, authorization, or clinical responsibilities not detailed here.

    • If a specific procedural or administrative action is required, it will be described in the Idaho Medicaid Provider Handbook.

    Eligibility Requirements

    Eligibility for coverage of cell-free fetal DNA testing is determined according to the Idaho Medicaid Provider Handbook. Providers must follow the Idaho Medicaid clinical coverage criteria and any member eligibility rules specified in that handbook when requesting or ordering testing.

    Any additional eligibility requirements (for example, state plan enrollment, program-specific limitations, or member benefit conditions) are governed by Idaho Medicaid policies and procedures as described in the Idaho Medicaid Provider Handbook. This policy does not define separate eligibility standards.

    Definitions

    cfDNA testing — definition and scope
    DefinitionCell-free fetal DNA (cfDNA) testing: laboratory analysis of circulating fetal DNA fragments in maternal blood to detect fetal antigens, single-gene variants, or chromosomal abnormalities as described by specific CPT codes.
    Examples of cfDNA test typesFetal antigen noninvasive prenatal tests (e.g., Rh, C, c, D, E, Fya, K), single-gene noninvasive prenatal tests (e.g., 0489U targets such as CFTR, SMN1, HBB, HBA1, HBA2), fetal RhD analysis by NGS (0494U) and PCR (0536U), and fetal chromosomal microdeletion analysis (81422).
    Coding notesSome CPT codes for cfDNA tests in this policy are marked with an asterisk (*) indicating they are not on the Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid (see policy for specific codes).

    Background

    This policy addresses cell-free fetal DNA (cfDNA) testing performed on maternal blood to detect fetal antigens, single-gene variants, and chromosomal abnormalities. Clinical coverage determinations and criteria for cfDNA testing in Idaho are delegated to the Idaho Medicaid Provider Handbook. Providers should refer to that handbook for the specific clinical indications, prior authorization rules, and any state-specific requirements that apply to cfDNA testing.

    Revision History

    08/01/2026material_changeLatest

    Medical Records Documentation Used for Reviews section was expanded to specify documentation that must support medical necessity and note that documentation does not guarantee coverage.

    08/01/2026clarification

    Added notation that CPT codes 0060U, 0488U, 0489U, 0494U, 0536U, and 81422 are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid; refer to the Idaho Medicaid Provider Handbook for non-covered and excluded services.

    Policy Summary
    PayerUnitedHealthcare
    PolicyCell-Free Fetal DNA Testing (for Idaho Only)
    Policy CodePolicy CS085ID.C
    Change TypeDocumentation expandedcoding clarification
    Effective DateAug 1, 2026
    Last ReviewAug 1, 2026
    Next Review Date
    Key ActionFollow Idaho Medicaid Provider Handbook for medical necessity criteria and ensure medical record documentation fully supports requested services.
    SourceLink
    On This Page
    Coverage Criteria (Idaho Medicaid Delegation)Coding and Procedure CodesProvider Actions, Authorization, and DocumentationEligibility RequirementsDefinitionsBackgroundRevision History
    Documentation Required

    Medical record documentation must support medical necessity

    The patient's medical record must contain documentation that fully supports medical necessity and may be requested for review.

    • Required documentation includes relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
    • Documentation should be legible, maintained in the patient’s medical record, and made available upon request.
    • Medical record documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage.
    Billing Rule

    Codes may be excluded from Idaho Medicaid fee schedule — check state fee schedule

    Claims for certain CPT codes listed in this policy may not be covered by Idaho Medicaid because they are not on the State of Idaho Medicaid Fee Schedule; check the state fee schedule and Idaho Medicaid Provider Handbook for claim/payment guidance.

    • Codes noted as not on the Idaho Medicaid Fee Schedule: 0060U, 0488U, 0489U, 0494U, 0536U, 81422.
    • Refer to the Idaho Medicaid Provider Handbook, General Information and Requirements for Providers: Non-Covered and Excluded Services, and the State of Idaho Medicaid Fee Schedule for reimbursement and billing guidance.
    Note

    Follow Idaho Medicaid Provider Handbook for counseling and clinical criteria

    Counseling and other clinical coverage criteria are governed by the Idaho Medicaid Provider Handbook; follow that handbook for required counseling content and related clinical requirements.

    • The policy references the Idaho Medicaid Provider Handbook for any counseling requirements that apply to genetic testing and cfDNA.
    Note

    Follow Idaho Medicaid Provider Handbook for authorized ordering provider types

    The policy does not specify which provider types may order cfDNA tests; providers must follow the Idaho Medicaid Provider Handbook and their contractual requirements regarding who may order and perform services.

    • Ensure ordering and billing provider meet Idaho Medicaid Provider Handbook and contract requirements.