ModifiedUnitedHealthcarePolicy CS017KS.04

Chromosome Microarray Testing (Non-Oncology Conditions) (for Kansas Only)

Policy governing medical necessity and coding guidance for chromosome microarray (cytogenic microarray) testing for non-oncology indications for members in Kansas. Applies to providers submitting claims or seeking coverage determinations in the state of Kansas.

Policy Summary

PayerUnitedHealthcare

PolicyChromosome Microarray Testing (Non-Oncology Conditions) (for Kansas Only)

Policy CodePolicy CS017KS.04

Change TypeReplaced state-specific guidelines with InterQual-based instruction

Effective DateFeb 1, 2026

Next Review Date

Key ActionUse InterQual CP: Molecular Diagnostics (WGS/WES/CMA) and Kansas Medical Assistance Program criteria for medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

Replaced coverage guidelines with instruction to refer to the InterQual® CP: Molecular Diagnostics, Whole Genome Sequencing (WGS), Whole Exome Sequencing (WES), and Chromosomal Microarray (CMA) for Congenital or Hereditary Disorders for medical necessity clinical coverage criteria.

Removed Definitions, Description of Services, and Clinical Evidence sections.

Updated References section to reflect the most current information.

Kansas-onlystate applicability

InterQualprimary criteria

Kansasgeographic

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Coverage and Medical Necessity Criteria

Medical necessity determination sources

Coverage requires meeting medical necessity criteria from the applicable authoritative source.

Primary rule: For Kansas members, medical necessity for cytogenetic microarray (chromosome microarray) testing is determined according to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual. For non-state-specific situations, InterQual CP: Molecular Diagnostics (WGS/WES/CMA) for Congenital or Hereditary Disorders is the referenced source for medical necessity determinations.

Providers must consult the cited sources for specific clinical scenarios and required documentation.

Coverage conditioned on InterQual criteria

Covered when medical necessity is demonstrated according to InterQual criteria.

InterQual-based medical necessity: Chromosomal microarray (CMA) testing is covered when ALL medical necessity criteria in InterQual CP: Molecular Diagnostics (Whole Genome Sequencing, Whole Exome Sequencing, and Chromosomal Microarray for Congenital or Hereditary Disorders) are met.refer to InterQual

This policy replaces prior state-specific coverage guidelines with instruction to refer to InterQual; follow state or contractual requirements where they differ.

Preimplantation genetic testing (PGT) is not covered under this Chromosome Microarray (CMA) policy. PGT is addressed separately in the Medical Policy titled Preimplantation Genetic Testing and Related Services (for Kansas Only); providers should follow that policy for any PGT-related prior authorization or coverage determinations.

FDA clearance or approval is provided for informational purposes only and FDA approval alone is not a basis for coverage. Genetic tests must be performed in laboratories that meet the requirements of the Clinical Laboratory Improvement Amendments (CLIA); testing performed outside CLIA-regulated settings does not meet the policy's regulatory expectations.

This policy replaces prior state-specific coverage guidelines for cytogenetic microarray testing with instruction to use InterQual® CP: Molecular Diagnostics (WGS/WES/CMA) for medical necessity determinations. Indications that do not meet InterQual criteria are not considered covered under this policy unless overridden by applicable federal, state, or contractual provisions that require otherwise.

Indications Considered for Coverage

Developmental delay, autism spectrum disorder, intellectual disability and other congenital or hereditary disorders where chromosomal abnormalities are suspected.

Covered indications represented by listed procedure and diagnosis codes; specific medical necessity criteria are in the Kansas manual or InterQual.

Indication set: Developmental delay, autism spectrum disorder, intellectual disability, and other congenital or hereditary disorders where chromosomal abnormalities are suspected.

See the procedure codes (e.g., 0156U, 0209U, 81228, 81229, 81349, 81479, S3870) and ICD-10 diagnosis codes (examples include F70–F79, F84.0, R62.0) listed in the policy for mapping clinical presentations to billing codes; specific medical necessity criteria must be confirmed in the Kansas manual or InterQual.

Suspected chromosomal abnormality or congenital malformation (prenatal or neonatal), including trisomies, microdeletions/microduplications, and other chromosomal syndromes.

Covered when chromosomal abnormality or congenital malformation is suspected in the prenatal or neonatal period.

Prenatal/neonatal suspicion: Suspected chromosomal abnormality or congenital malformation (prenatal or neonatal), including trisomies, microdeletions/microduplications, and other chromosomal syndromes.

Procedure and Diagnosis Codes

Procedure codes referencedmixed

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
S3870	Comparative genomic hybridization (CGH) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability

Selected diagnosis codes (examples)ICD-10

F70	Mild intellectual disabilities.
F71	Moderate intellectual disabilities.
F72	Severe intellectual disabilities.
F73	Profound intellectual disabilities.
F79	Unspecified intellectual disabilities.
F80.0	Phonological disorder.
F84.0	Autistic disorder.
H93.25	Central auditory processing disorder.
N96	Recurrent pregnancy loss.
O35.10X0	Maternal care for (suspected) chromosomal abnormality in fetus, unspecified.

Listed ICD-10 Diagnosis CodesICD-10

O35.13X5	Maternal care for (suspected) chromosomal abnormality in fetus, Trisomy 21, fetus 5
O35.13X9	Maternal care for (suspected) chromosomal abnormality in fetus, Trisomy 21, other fetus
O35.14X0	Maternal care for (suspected) chromosomal abnormality in fetus, Turner Syndrome, not applicable or unspecified
O35.14X1	Maternal care for (suspected) chromosomal abnormality in fetus, Turner Syndrome, fetus 1
O35.15X0	Maternal care for (suspected) chromosomal abnormality in fetus, sex chromosome abnormality, not applicable or unspecified
O35.19X0	Maternal care for (suspected) chromosomal abnormality in fetus, other chromosomal abnormality, not applicable or unspecified
O35.2XX0	Maternal care for (suspected) hereditary disease in fetus, not applicable or unspecified
O36.4XX0	Maternal care for intrauterine death, not applicable or unspecified
P02.9	Newborn affected by abnormality of membranes, unspecified
P95	Stillbirth

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inv-09: Regulatory requirement — Testing laboratories must comply with CLIA regulations

Regulatory requirementTesting laboratories must comply with Clinical Laboratory Improvement Amendments (CLIA) regulations; genetic tests are regulated under CLIA of 1988.

FDA informational roleFDA approval or clearance is provided for informational purposes only and is not a basis for coverage determination.

FDA resourcePolicy references FDA guidance pages for in vitro diagnostics and nucleic acid–based tests for additional information.

What Providers Must Do

Billing Rule

Applicable Codes (Reference Only)

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

Applicable codes listed for reference only — providers should follow benefit terms and applicable laws.
Coding inclusion does not guarantee coverage or payment; check federal, state, and contractual requirements.

Prior Authorization

Use InterQual Criteria for Medical Necessity

Member Eligibility and Policy Applicability

No additional policy-level eligibility criteria are specified in this document. Coverage and medical necessity determinations should follow the applicable authoritative sources (Kansas Medical Assistance Program requirements for Kansas members and InterQual® CP: Molecular Diagnostics for non-state-specific criteria) and any applicable federal, state, or contractual benefit terms.

There are no top-level eligibility nodes defined in this policy. Providers must refer to the stated medical necessity sources—Kansas-specific program guidance where applicable, and InterQual® CP: Molecular Diagnostics—for specific patient eligibility and documentation requirements.

This policy does not list additional enrollment or member-specific eligibility requirements at the policy level. Determinations about member eligibility for testing should be made in accordance with the applicable plan, state rules, and the referenced clinical criteria sources.

Services Not Covered / Limitations

The policy no longer contains standalone coverage rules authored here; prior explicit coverage guidelines were removed and replaced with instruction to apply InterQual® CP: Molecular Diagnostics (WGS/WES/CMA) criteria for medical necessity determinations. Providers should follow InterQual and any applicable state or contractual processes for prior authorization and coverage decisions.

Background and Definitions

Chromosome microarray (also called cytogenetic microarray or CMA) is a genome-wide test used to detect copy number variants and structural chromosomal abnormalities associated with congenital or hereditary disorders. This policy directs providers to the Kansas Medical Assistance Program guidance for Kansas members and to InterQual® CP: Molecular Diagnostics (WGS/WES/CMA) for detailed clinical coverage criteria and documentation requirements.

inv-20: Chromosome microarray / cytogenomic analysis — Definition and scope

DefinitionChromosome microarray / cytogenomic analysis: genome-wide analysis interrogating genomic regions for copy number variants, structural changes, single nucleotide polymorphism (SNP) variants, or loss-of-heterozygosity using comparative genomic hybridization (CGH) microarray or low-pass sequencing analysis.

Common modalitiesIncludes CGH microarray, SNP microarray, and low-pass sequencing cytogenomic analyses (CPT codes 81228, 81229, 81349; HCPCS S3870).

Typical clinical useUsed to detect constitutional chromosomal abnormalities for developmental delay, autism spectrum disorder, intellectual disability, and other congenital or hereditary disorders.