CurrentUnitedHealthcarePolicy CS017KS.04

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

State-specific UnitedHealthcare medical policy applying only to Kansas for chromosome microarray testing (non-oncology). It directs use of Kansas Medical Assistance Program criteria for state-specific coverage and delegates non-state-specific clinical criteria to InterQual CP for molecular diagnostics including CMA for congenital or hereditary disorders.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS017KS.04

Change TypeRevised to reference InterQual; removed sections

Effective DateFeb 1, 2026

Next Review Date

Key ActionFor Kansas members reference the Kansas Medical Assistance Program manual for state-specific criteria and use InterQual CP: Molecular Diagnostics (WGS/WES/CMA) for non-state-specific clinical coverage criteria when requesting CMA.

POLICY UPDATE CHANGES

Replaced coverage guidelines with instruction to refer to the InterQual CP for CMA, WES, and WGS for medical necessity clinical coverage criteria.

Updated Supporting Information and References to reflect current information and removed Definitions, Description of Services, and Clinical Evidence sections.

Replaced coverage guidelines with instruction to refer to the InterQual CP: Molecular Diagnostics (WGS, WES, CMA) for medical necessity clinical coverage criteria.

Updated Supporting Information/References section to reflect most current information.

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

Archived previous policy version CS017KS.03.

1State(s) applicable

1Reference to External Criteria (InterQual)

7CPT/HCPCS codes listed

>40ICD-10 codes listed

Coverage Summary

This policy addresses Chromosome microarray testing (CMA) for non-oncology conditions and is specific to the state of Kansas. Policy number: CS017KS.04. Effective date: February 1, 2026. Status: CURRENT. This Medical Policy applies only to Kansas and delegates state-specific medical necessity criteria to the Kansas Medical Assistance Program; non-state-specific clinical criteria are delegated to InterQual.

Key facts

State(s) applicableKansas (policy applies only to the state of Kansas)

Reference to External Criteria (InterQual)InterQual CP: Molecular Diagnostics (WGS, WES, CMA) — used for non-state-specific medical necessity criteria

CPT/HCPCS codes listed (count)7

ICD-10 codes listed (count)>40

Removed Sections (count)3 (Definitions, Description of Services, Clinical Evidence)

Effective dateFebruary 1, 2026

Last review dateFebruary 1, 2026

Policy numberCS017KS.04

Medical-Necessity Criteria

State-Specific Criteria

For medical necessity clinical coverage criteria for cytogenic microarray (chromosome microarray) testing:

Policy applies only to the state of Kansas.
Refer to the Kansas Medical Assistance Program, Professional Fee-for-Service Provider Manual for Kansas-specific medical necessity clinical coverage criteria for CMA testing.

Non State-Specific Criteria

For non-state-specific medical necessity clinical coverage criteria:

Refer to 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.

Coding

Referenced CPT / Proprietary CodesCPT

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

Referenced ICD-10 Diagnosis Codes (examples listed in policy)ICD-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 352

1/36

Provider Actions

Documentation Required

Use state and InterQual criteria to support medical necessity

For members in Kansas, providers must reference the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for state-specific medical necessity criteria; for non-state-specific clinical criteria, providers must reference InterQual CP: Molecular Diagnostics, WGS, WES, and CMA for Congenital or Hereditary Disorders when submitting for coverage determination.

Reference the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for Kansas-specific criteria.
When applicable, cite InterQual CP: Molecular Diagnostics (WGS/WES/CMA) for non-state-specific clinical criteria in the submission.
Include any relevant Kansas contractual or federal requirements that may override standard plan language.

Documentation Required

Use InterQual criteria for medical necessity

Background

UnitedHealthcare’s Kansas-specific medical policy covers chromosome microarray testing (CMA) for non-oncology conditions. For Kansas-specific medical necessity clinical coverage criteria, the policy directs providers to the Kansas Medical Assistance Program, Professional Fee‑for‑Service Provider Manual. For non-state‑specific clinical coverage criteria, the policy delegates determinations to InterQual CP: Molecular Diagnostics (WGS, WES, CMA) for Congenital or Hereditary Disorders. The policy revision replaced internal coverage guidelines with instructions to refer to InterQual and archived the prior version.

Revision History

02/01/2026MaterialLatest

Replaced coverage guidelines with instruction to refer to the InterQual CP for CMA, WES, and WGS for medical necessity clinical coverage criteria.

02/01/2026Non-materialLatest

Updated Supporting Information and References to reflect current information and removed Definitions, Description of Services, and Clinical Evidence sections.

02/01/2026Material

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS017KS.04

Change TypeRevised to reference InterQual; removed sections

Effective DateFeb 1, 2026

Next Review Date

On This Page

Coverage Rationale / Medical Necessity Determination

Refer to 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.

Coverage and medical necessity determinations for CMA testing are governed by InterQual CP: Molecular Diagnostics (Whole Genome Sequencing, Whole Exome Sequencing, and Chromosomal Microarray) clinical criteria.
When InterQual does not have applicable criteria, UnitedHealthcare may use UnitedHealthcare Medical Policies approved by the Kansas Department of Health and Environment.
Federal, state, or contractual requirements for benefit plan coverage override the standard benefit plan when there is a conflict.

Providers must reference InterQual CP: Molecular Diagnostics (WGS/WES/CMA) for clinical coverage criteria when requesting CMA for congenital or hereditary disorders; if InterQual lacks applicable criteria, use UnitedHealthcare Medical Policies that have been approved by the Kansas Department of Health and Environment.

Cite InterQual CP: Molecular Diagnostics (WGS/WES/CMA) when submitting for coverage determination.
If InterQual does not have applicable criteria, reference UnitedHealthcare Medical Policies approved by the Kansas Department of Health and Environment as the fallback.

Prior Authorization

Prior authorization governed by InterQual/plan

Authorization and coverage decisions will follow InterQual medical necessity criteria and any applicable federal, state, or contractual plan requirements; providers should verify plan-specific authorization processes and state requirements before submitting requests.

Check the member’s plan for any plan-specific prior-authorization portal or form requirements.
Confirm Kansas state requirements that may affect authorization or coverage (policy applies only to Kansas).
Ensure documentation references InterQual CP criteria used to support medical necessity.