CurrentUnitedHealthcarePolicy CS085KS.04

Cell‑Free Fetal DNA Testing (for Kansas Only)

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Policy governing coverage and clinical documentation expectations for DNA-based noninvasive prenatal tests (cfDNA) for fetal aneuploidy and related testing for members covered under UnitedHealthcare in the state of Kansas.

Policy Summary

PayerUnitedHealthcare

PolicyCell‑Free Fetal DNA Testing (for Kansas Only)

Policy CodePolicy CS085KS.04

Change TypeCode additions and quarterly code list update

Effective Date08/01/2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionFollow the Kansas Medical Assistance Program provider manual for clinical criteria and ensure medical records document medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added CPT codes 0632U and 0633U to the list of applicable CPT codes.

Updated list of applicable CPT codes to reflect quarterly edits.

Kansas-onlyjurisdiction applicability

>8CPT/HCPCS codes listed (including unlisted code)

1related payer policy references

08/01/2026

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CurrentUnitedHealthcarePolicy CS085KS.04

Cell‑Free Fetal DNA Testing (for Kansas Only)

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Policy Summary

PayerUnitedHealthcare

PolicyCell‑Free Fetal DNA Testing (for Kansas Only)

Policy CodePolicy CS085KS.04

Change TypeCode additions and quarterly code list update

Effective Date08/01/2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionFollow the Kansas Medical Assistance Program provider manual for clinical criteria and ensure medical records document medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added CPT codes 0632U and 0633U to the list of applicable CPT codes.

Updated list of applicable CPT codes to reflect quarterly edits.

Kansas-onlyjurisdiction applicability

>8CPT/HCPCS codes listed (including unlisted code)

1related payer policy references

08/01/2026

Coverage Criteria

State-defined medical necessity

Covered when medical necessity criteria from the Kansas Medical Assistance Program are met:

state_program_criteria: Coverage for DNA-based noninvasive prenatal tests of fetal aneuploidy is determined by the Kansas Medical Assistance Program: Professional Fee-for-Service Provider Manual (referenced).

Policy directs providers to state program clinical criteria; specific clinical test-entry criteria are defined in that manual.

The listing of a procedure or diagnosis code in this policy is provided for reference only and does not imply that the service described by the code is either a covered or non-covered health service. Coverage determinations, reimbursement rights, and claim payment are governed by applicable federal, state, or contractual requirements and laws; other policies and guidelines may also apply. The inclusion of a code in this policy does not guarantee coverage or payment.

Information about U.S. Food and Drug Administration (FDA) clearance or approval and Clinical Laboratory Improvement Amendments (CLIA) regulation is provided for informational purposes only. FDA approval alone is not a basis for coverage. Laboratories that perform DNA-based tests are regulated under CLIA; refer to the FDA and CLIA resources cited in the policy for additional details.

Fetal antigen (Rh and other red blood cell antigens) analysis, single-gene paternal variant detection, fetal chromosomal microdeletion analysis via cfDNA.

Covered indications (clinical coverage and test-entry criteria are determined by the Kansas Medical Assistance Program):

covered_indications: Fetal antigen analysis (including RhD and other red blood cell antigens) via cfDNA for assessment of fetal antigen status in alloimmunized pregnancies or when maternal RhD-negative status is known.

Refer to state manual for exact eligibility and gestational age thresholds (e.g., RHD PCR testing at 10+ weeks).

covered_indications: Single-gene noninvasive prenatal tests via cfDNA to detect paternally inherited pathogenic variants (examples: CFTR, SMN1, HBB, HBA1, HBA2) and to assess fetal inheritance when maternal mutation is present.

State program criteria define specific clinical indications and prior testing requirements.

covered_indications: Fetal chromosomal microdeletion analysis via cfDNA (e.g., 22q11.2/DiGeorge, Cri-du-chat) when clinical criteria in the Kansas Medical Assistance Program are met.

Coverage depends on state program clinical criteria; laboratories regulated under CLIA and FDA status is informational only.

coding_references: Applicable procedure codes (reference only): 0488U (fetal antigen cfDNA), 0489U and 0633U (single-gene cfDNA tests), 0494U/0536U/0632U (RHD/fetal RhD testing), 81422 (fetal chromosomal microdeletion genomic sequence analysis), 81479 (unlisted molecular pathology).

Coding

Applicable CPT Codes (excerpt)CPT

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 CPT Codes (continued)CPT

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 (eg, 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.

Other molecular pathology codes referencedCPT

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-07: Gestational age for RHD PCR test — 10+ weeks

Gestational age threshold10+ weeks gestation for PCR-based RHD (exon 4) analysis

Test method referencedPCR analysis of exon 4 of RHD gene with GAPDH control from whole blood

Intended populationPregnant individuals known to be RhD negative

Provider Actions and Requirements

Prior Authorization

Follow Kansas Medical Assistance Program clinical criteria

Coverage determinations for DNA-based noninvasive prenatal tests of fetal aneuploidy are governed by the Kansas Medical Assistance Program: Professional Fee-for-Service Provider Manual; follow that state program clinical criteria when ordering or seeking coverage.

Applicable CPT/HCPCS codes listed in this policy are for reference; actual coverage depends on state program criteria.

Note

Align orders with Kansas Medical Assistance Program requirements

Ordering and coverage must align with the Kansas Medical Assistance Program requirements; the UnitedHealthcare policy defers to the state manual for specific clinical entry criteria and does not itself specify ordering-provider specialty.

Ensure orders meet the state program’s clinical criteria before submitting for coverage.

Background

This policy addresses DNA-based noninvasive prenatal tests (cell-free fetal DNA, cfDNA) performed on maternal blood to detect fetal chromosomal aneuploidy, targeted single-gene inheritance, and fetal red blood cell antigen status. Clinical coverage and specific medical necessity criteria for these tests are determined by the Kansas Medical Assistance Program: Professional Fee-for-Service Provider Manual, which is the referenced source for clinical decision-making under this Kansas-only policy.

Definitions

inv-13: Cell-free fetal DNA testing (cfDNA) definition and scope.

DefinitionDNA-based noninvasive prenatal tests performed on maternal blood to detect fetal chromosomal aneuploidy, specific single-gene targets, or fetal red blood cell antigen status (e.g., RhD).

Included test typesFetal antigen (Rh and other red blood cell antigens) analysis, single-gene noninvasive prenatal tests for paternally inherited variants, and fetal chromosomal microdeletion analysis via cfDNA.

Typical methodsNext‑generation sequencing (NGS), multiplex PCR, and targeted cfDNA sequence analysis depending on the CPT code/test.

Coding examplesRepresentative CPT codes: 0488U (fetal antigen cfDNA), 0489U/0633U (single‑gene cfDNA), 0494U/0536U/0632U (fetal RhD/antigen analysis), 81422 (microdeletion), 81479 (unlisted molecular).

Not Covered / Limitations

This document does not explicitly list any tests or clinical indications as not covered. The codes included are for reference only and do not by themselves indicate coverage status; coverage is determined by federal, state, or contractual requirements and the applicable Kansas program criteria.

Revision History

2026-08-01codes_updatedLatest

Updated list of applicable CPT codes to reflect quarterly edits and added CPT codes 0632U and 0633U.

2026-08-01archived_previous_version

Archived previous policy version CS085KS.03.