DraftUnitedHealthcarePolicy CS017OH.F

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

This policy governs coverage and coding guidance for chromosome microarray testing for non-oncology indications for UnitedHealthcare members in Ohio. It applies to providers requesting CMA and related molecular diagnostic services in Ohio.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS017OH.F

Change TypeCode list update (ICD-10 additions/removals)

Effective DateJan 1, 2026

Next Review Date

Key ActionCheck plan-specific prior authorization requirements and apply InterQual CP: Molecular Diagnostics for medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

Added ICD-10 diagnosis codes Q89.89, Q99.89, QA0.0159, and QA0.8 to Applicable Codes.

Removed ICD-10 diagnosis codes Q89.8 and Q99.8 from Applicable Codes.

Archived previous policy version CS017OH.E in supporting information.

Ohiogeographic scope

InterQualclinical criteria source

4ICD-10 codes added

2ICD-10 codes removed

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Coverage Criteria

InterQual-derived CMA coverage

Covered when ALL of the following are met per InterQual CP: Molecular Diagnostics (WGS/WES/CMA):

InterQual-based medical necessity: Medical necessity clinical coverage criteria are determined by the InterQual CP: Molecular Diagnostics, Whole Genome Sequencing (WGS), Whole Exome Sequencing (WES), and Chromosomal Microarray (CMA) for Congenital or Hereditary Disorders (refer to InterQual for the full logic).

See InterQual referenced in policy

Preimplantation genetic testing (PGT) is not covered under this Chromosome Microarray Testing policy. PGT is addressed under the separate UnitedHealthcare Medical Policy titled Preimplantation Genetic Testing and Related Services (for Ohio Only), and providers should follow that policy for coverage and prior authorization questions related to PGT.

FDA clearance or approval of a genetic test is provided for informational purposes only and FDA approval alone is not a basis for coverage. Coverage determinations rely on federal, state, or contractual requirements and the clinical criteria referenced in this policy (for example, InterQual criteria), not solely on FDA status.

Covered Indications

Evaluation of congenital or hereditary disorders (CMA per InterQual)

Covered indications per InterQual for evaluation of congenital or hereditary disorders include the following clinical contexts:

Indication set: Evaluation of congenital or hereditary disorders (e.g., developmental delay, autism spectrum disorder, intellectual disability) using chromosomal microarray testing per InterQual.

Policy references InterQual for specific indications and links applicable CMA procedure codes (e.g., 0209U, 81228, 81229, 81349, S3870).

Coding — Procedure and Diagnosis Codes

Applicable procedure codesmixed

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

Applicable diagnosis codesICD-10

F70	Mild intellectual disabilities.
F71	Moderate intellectual disabilities.
F72	Severe intellectual disabilities.
F73	Profound intellectual disabilities.
F78.A1	SYNGAP1-related intellectual disability.
F78.A9	Other genetic related intellectual disability.
F79	Unspecified intellectual disabilities.
F80.0	Phonological disorder.
F80.1	Expressive language disorder.
F80.2	Mixed receptive-expressive language disorder.

1–10 of 71

1/8

Applicable ICD-10 Codes (maternal care for suspected chromosomal/hereditary fetal abnormalities) - partICD-10

O35.15X5	Maternal care for (suspected) chromosomal abnormality in fetus, sex chromosome abnormality, fetus 4
O35.15X9	Maternal care for (suspected) chromosomal abnormality in fetus, sex chromosome abnormality, other fetus
O35.19X0	Maternal care for (suspected) chromosomal abnormality in fetus, other chromosomal abnormality, not applicable or unspecified
O35.19X1	Maternal care for (suspected) chromosomal abnormality in fetus, other chromosomal abnormality, fetus 1

Applicable ICD-10 Codes (continued maternal/newborn/fetal conditions)ICD-10

O35.2XX1	Maternal care for (suspected) hereditary disease in fetus, fetus 1
O35.8XX0	Maternal care for other (suspected) fetal abnormality and damage, not applicable or unspecified
O35.AXX0	Maternal care for other (suspected) fetal abnormality and damage, fetal facial anomalies, not applicable or unspecified
O35.BXX0	Maternal care for other (suspected) fetal abnormality and damage, fetal cardiac anomalies, 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

Applicable ICD-10 Codes (congenital cardiac and common chromosomal diagnoses)ICD-10

Q20.1	Double outlet right ventricle
Q21.0	Ventricular septal defect
Q21.3	Tetralogy of Fallot
Q90.0	Trisomy 21, nonmosaicism (meiotic nondisjunction)
Q91.0	Trisomy 18, nonmosaicism (meiotic nondisjunction)

Applicable ICD-10 Codes (other chromosomal/microdeletion syndromes)ICD-10

Q92.0	Whole chromosome trisomy, nonmosaicism (meiotic nondisjunction)
Q93.4	Deletion of short arm of chromosome 5
Q93.51	Angelman syndrome
Q93.52	Phelan-McDermid syndrome
Q93.81	Velo-cardio-facial syndrome

Applicable ICD-10 Codes (recent additions and unspecified chromosomal abnormalities)ICD-10

Q99.9	Chromosomal abnormality, unspecified
Q89.89	Other specified congenital malformations (added)
Q99.89	Other specified chromosome abnormalities (added)
QA0.0159	Neurodevelopmental disorder, related to other genes associated with transcription and gene expression (added)
QA0.8	Other neurodevelopmental disorders related to pathogenic variants in other specific genes (added)

Applicable ICD-10 Codes (screening and history)ICD-10

Z36.0	Encounter for antenatal screening for chromosomal anomalies
Z87.74	Personal history of (corrected) congenital malformations of heart and circulatory system

Provider Actions and Billing Notes

Prior Authorization

Prior Authorization and Applicable Codes

Prior authorization may be required for Chromosome Microarray (CMA) testing in Ohio. Providers should obtain any required prior authorization per the member's plan before performing testing.

Reference applicable procedure codes (e.g., 0156U) when submitting authorization and claims.
Listing of a code in this policy does not imply coverage; check plan-specific benefit documents.

Prior Authorization

Check Prior Authorization per Plan

Check the member's specific plan, federal, and Ohio state (OAC) requirements for prior authorization and coverage before ordering testing. Plan or contractual terms may impose different requirements than this policy.

Verify prior authorization and benefit coverage in the enrollee's plan.
If plan documents or contracts differ from this policy, those documents govern coverage.

Eligibility Requirements

Eligibility requirements for Chromosome Microarray Analysis (CMA) in this policy are determined by the external InterQual clinical criteria referenced herein. There are no standalone top-level eligibility nodes listed directly in this document; providers should refer to the InterQual CP: Molecular Diagnostics (WGS/WES/CMA) for the detailed medical necessity logic and specific eligibility pathways.

Not Covered

The policy lists procedure and diagnosis codes for reference, but listing a code in this policy does not imply coverage. Benefit coverage for any service is determined by applicable federal, state, or contractual requirements and other UnitedHealthcare policies; the absence of an explicit excluded-test list in this section does not change that standard.

Background

Chromosomal microarray analysis (CMA) is a genome-wide laboratory test that interrogates genomic regions to detect copy number variants, structural changes, and areas of homozygosity associated with constitutional chromosomal abnormalities. Common CMA test types referenced in this policy include comparative genomic hybridization (CGH) microarray, single nucleotide polymorphism (SNP) microarray, and low-pass sequencing approaches. This policy defers to the InterQual CP: Molecular Diagnostics (WGS/WES/CMA) for the clinical criteria used to determine medical necessity for CMA in congenital or hereditary disorders.

Definitions

inv-21: Chromosomal microarray analysis (CMA)

DefinitionChromosomal microarray analysis (CMA) — genome-wide analysis interrogating genomic regions for copy number variants, structural changes, and areas of homozygosity (examples: CGH microarray, SNP microarray, low‑pass sequencing).

Common test methodsComparative genomic hybridization (CGH) microarray and SNP microarray — used to detect CNVs and structural rearrangements.

Alternative/related methodsLow‑pass sequencing analysis — interrogates copy number and loss‑of‑heterozygosity variants as an alternative CMA approach.

Procedure codes referencedPolicy references procedure codes for CMA and related analyses including 0209U, 81228, 81229, 81349, 81479, S3870.

Typical clinical useEvaluation of developmental delay, autism spectrum disorder, and/or intellectual disability — CGH/SNP microarray platforms are specifically linked to these indications (see S3870 description).

Revision History

2026-01-01codes_addedLatest

Added ICD-10 diagnosis codes Q89.89, Q99.89, QA0.0159, and QA0.8 to the Applicable Codes list.

2026-01-01codes_removed

Removed ICD-10 diagnosis codes Q89.8 and Q99.8 from the Applicable Codes list.

2026-01-01administrative