CurrentUnitedHealthcarePolicy CS160ID.C

Preimplantation Genetic Testing and Related Services (for Idaho Only)

Policy governing coverage and clinical documentation expectations for preimplantation genetic testing and related reproductive services for UnitedHealthcare members in Idaho (including Idaho Medicaid Plus).

Policy Summary

PayerUnitedHealthcare

PolicyPreimplantation Genetic Testing and Related Services (for Idaho Only)

Policy CodePolicy CS160ID.C

Change TypeAdded documentation requirementsadded 4 CPT/PLA codes

Effective DateMay 1, 2026

Next Review Date

Key ActionWhen requesting coverage, reference this policy and provide legible medical record documentation that supports medical necessity, including history, exam, and relevant test results.

SourceLink

POLICY UPDATE CHANGES

Added language specifying required medical records documentation to support medical necessity for requested services.

Added CPT codes 0552U, 0553U, 0554U, and 0555U to the applicable codes list.

4new CPT/PLA codes added (0552U-0555U)

1state-specific application (Idaho only)

~30applicable codes listed

Coverage criteria and rationale

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Clinical criteria sourcing — coverage rationale

Coverage rationale

Coverage determination: Coverage and medical necessity criteria for genetic testing are governed by the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8: Genetic Testing; this policy does not restate those clinical criteria.

Refer to the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8 for the specific clinical indications and medical necessity rules.

The list of procedure and diagnosis codes included in this policy is provided for reference only. Listing a code does not imply the service described by the code is a covered or non-covered health service, nor does it guarantee reimbursement or payment; coverage is determined by applicable federal, state, or contractual requirements and applicable laws.

This policy does not enumerate an explicit list of services that are 'not medically necessary.' Coverage determinations depend on applicable federal, state, or contractual requirements and must be made in accordance with those rules; for clinical medical necessity criteria for genetic testing, refer to the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8: Genetic Testing.

Member eligibility requirements

Eligibility for coverage of preimplantation genetic testing and related services is governed by the clinical medical necessity criteria in the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8: Genetic Testing. This policy does not restate or replace those handbook criteria; providers must confirm member eligibility and coverage rules per that handbook and applicable plan/federal/state contract requirements.

Additional eligibility considerations such as who may order testing, counseling requirements, prior testing, or step therapy are not specified in this document and are subject to plan, federal, or state contractual rules. Providers should follow the Idaho Medicaid Provider Handbook for any clinical prerequisites and confirm prior authorization requirements with the plan before ordering services.

Applicable CPT/PLA and related codes

Covered CPT/PLA Codes (referenced)CPT

0254U

Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score in euploid embryos, results reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental aneuploidy, per embryo tested

Added CPT/PLA CodesCPT

0552U	Reproductive medicine (preimplantation genetic assessment), analysis for known genetic disorders from trophectoderm biopsy, linkage analysis of disease-causing locus, and when possible, targeted mutation analysis for known familial variant, reported as low-risk or high-risk for familial genetic disorder
0553U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, and a mitochondrial DNA score, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental
0554U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal (euploidy), monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as
0555U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested

Applicable Codes (referenced)mixed

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.
89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos.
89291	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos.
58970	Follicle puncture for oocyte retrieval, any method.
58974	Embryo transfer, intrauterine.
76948	Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation.
89250	Culture of oocyte(s)/embryo(s), less than 4 days.

1–10 of 30

1/3

Unit of reporting: per embryo tested

Definition'Per embryo tested' is the unit of reporting for many PLA/CPT codes used for preimplantation genetic assessment (e.g., 0254U and 0555U).

Example codes using this unit0254U — results reported per embryo tested (aneuploidy, mitochondrial DNA score, mosaicism, segmental aneuploidy).

Additional PLA codes0555U — reproductive medicine preimplantation genetic assessment reported 'per embryo tested' (structural rearrangements, aneuploidy, ploidy, mitochondrial DNA score, quality control).

Billing implicationWhen submitting claims for tests described by these PLA/CPT codes, report the service quantity based on the number of embryos tested.

Provider responsibilities and documentation

Prior Authorization

Reference policy for authorization

Providers should reference this UnitedHealthcare medical policy (Policy Number: CS160ID.C) and applicable federal, state, or contractual benefit plan requirements when requesting prior authorization or coverage determination. In the event of a conflict, the federal, state, or contractual requirements govern.

Note

Documentation Required

Required medical records

Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws, which may require coverage for a specific service. Medical records documentation may be requested to assess whether the member meets clinical criteria for coverage but does not guarantee coverage of the services requested. The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. This documentation includes, but is not limited to, relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures. Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available upon request.

Denial Risk

Documentation insufficiency

If the medical record documentation is incomplete, illegible, or does not support the medical necessity for the requested service, the request may be denied or UnitedHealthcare may be unable to determine medical necessity. Providers should ensure records are complete and available upon request to avoid delays or denials.

Note

Reference Idaho Medicaid clinical criteria

For clinical coverage criteria, counseling requirements, or other program-specific rules that apply to Idaho members, providers must refer to the Idaho Medicaid Provider Handbook, Laboratory Services, Chapter 4.8: Genetic Testing, and follow any additional Idaho contractual requirements.

Note

Ordering-provider requirements

This policy does not specify who may order tests. Ordering and ordering-provider eligibility must follow the applicable plan, federal, and state contractual rules and regulations.

Definitions and key terms

Preimplantation genetic testing / assessment — definition

TermPreimplantation genetic testing / assessment: laboratory analysis performed on embryonic material (e.g., trophectoderm biopsy) to assess aneuploidy, structural rearrangements, known familial variants, and mitochondrial DNA score; results are reported per embryo tested.

Examples of analyses includedTargeted familial variant analysis and linkage (e.g., 0552U); genome-wide chromosome analysis for aneuploidy, structural rearrangements, and mitochondrial DNA scoring (e.g., 0553U, 0554U, 0555U, 0254U).

Specimen/sourceEmbryonic material such as trophectoderm biopsy or embryonic DNA obtained from biopsy.

Result reporting conventionsResults may be reported as euploid/normal, monosomy, trisomy, partial deletions/duplications, mosaicism, unbalanced/balanced structural rearrangements, ploidy abnormalities, and quality-control findings (e.g., contamination detected).

OpenPayer

Preimplantation Genetic Testing and Related Services (for Idaho Only)

Coverage criteria and rationale

Covered indications

Member eligibility requirements

Applicable CPT/PLA and related codes

Provider responsibilities and documentation

Non-covered items and exclusions

Definitions and key terms

Background and related references