CurrentUnitedHealthcarePolicy CS16OKS.02

Preimplantation Genetic Testing and Related Services (for Kansas Only)

This policy governs coverage and coding references for preimplantation genetic testing (PGT) and related services for UnitedHealthcare members in the state of Kansas. It is intended for providers performing or ordering PGT and associated reproductive procedures.

Policy Summary

PayerUnitedHealthcare

PolicyPreimplantation Genetic Testing and Related Services (for Kansas Only)

Policy CodePolicy CS16OKS.02

Change TypeCodes added/updated

Effective DateJul 1, 2025

Next Review Date

Key ActionFollow the member's federal, state, or contractual benefit requirements and any plan-specific prior authorization processes before ordering or billing PGT services.

SourceLink

POLICY UPDATE CHANGES

Added CPT/HCPCS level II codes 0552U, 0553U, 0554U, and 0555U to the applicable codes list.

Updated list of applicable CPT codes to include new reproductive medicine and PGT-specific codes (0254U, 0552U-0555U, 81228, 81229, 81349, 81479, 89290-89291, and others).

~20+Procedure and billing codes listed for reference

1State-specific applicability (Kansas only)

1Related payer policy archived (previous version)

Coverage and Medical Necessity

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Medical necessity governed by Kansas Medicaid manual

Coverage and medical necessity for genetic analysis (genetic testing) related to preimplantation genetic testing (PGT) are determined by reference to Kansas Medical Assistance Program criteria:

Kansas-specific medical necessity: Medical necessity clinical coverage criteria for genetic analysis (genetic testing) are defined in the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual and must be followed for coverage determinations.

Refer to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for the specific clinical criteria, indications, and documentation requirements; the manual is available at the Kansas Medical Assistance Program provider resources website (see References).

The list of procedure and diagnosis codes in this policy is provided for reference only. Listing of a code in this policy does not imply the service is covered; benefit coverage and reimbursement are determined by applicable federal, state, or contractual requirements and laws. The inclusion of a code does not guarantee payment and other policies or guidelines may apply.

This policy does not itself define conditions that are not medically necessary (NMN). Determinations about NMN and coverage decisions must follow the governing benefit documents (for example, plan, state, or federal terms) rather than the code listings or the policy text alone.

Indications for PGT coverage

Indications for PGT coverage are those that meet the medical necessity criteria specified in the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual:

Covered indications: Indications for preimplantation genetic testing (PGT) coverage are those meeting the medical necessity criteria in the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual.

Specific covered indications (for example: known parental pathogenic variant for PGT‑M, recurrent pregnancy loss attributable to parental chromosomal rearrangement for PGT‑SR, advanced maternal age or other indications for PGT‑A) are not enumerated in this policy and must be confirmed in the Kansas manual.

Procedure and Billing Codes

PGT-specific molecular pathology/proprietary CPT codesCPT

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, per embryo tested.
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, per embryo tested.

Additional PGT and cytogenomic CPT codesmixed

0554U	Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, per embryo tested.
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, per embryo tested.
81228	Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; 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, 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.

Related reproductive procedure and service codesmixed

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.
89251	Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture.
89253	Assisted embryo hatching, microtechniques.
89254	Oocyte identification from follicular fluid.
89255	Preparation of embryo for transfer (any method).
89257	Sperm identification from aspiration (other than seminal fluid).
89258	Cryopreservation; embryo(s).

1–10 of 24

1/3

Embryo biopsy count for CPT split — 89290 / 89291

89290Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos.

89291Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos.

Usage noteAssign 89290 when performing embryo biopsy for up to 5 embryos; assign 89291 when biopsy exceeds 5 embryos.

Provider Responsibilities and Authorization

Prior Authorization

Follow benefit-specific prior authorization requirements

Coverage decisions must follow the member's federal, state, and contractual benefit terms. Providers should verify applicable benefit documents and plan language before ordering tests or submitting claims; when there is a conflict between this Medical Policy and a member's governing benefit documents, the federal, state, or contractual requirements govern.

Follow the member's federal, state, and contractual benefit requirements when determining coverage or authorization.
When in conflict, federal/state/contractual requirements supersede this policy.

Documentation Required

Reference governing benefit documents

Providers must reference and comply with all applicable federal, state, and contractual requirements (for example, state Medicaid program manuals) when ordering genetic testing and related services. Documentation submitted for prior authorization or claim adjudication should align with those governing benefit documents.

Ensure documentation supports medical necessity per the member's governing benefit documents.
Reference state program manuals (e.g., Kansas Medical Assistance Program) for any program-specific requirements, including pre- or post-test genetic counseling if required.

Note

Code listing is informational; coverage depends on benefit terms

The code list in this policy is informational only. Inclusion of a code does not guarantee coverage or reimbursement — benefit coverage is determined by the member's plan terms and applicable laws.

Listing of a code in this policy does not imply the service is covered.
Verify coverage and reimbursement eligibility with the member's plan and applicable contractual rules.

Documentation Required

Follow applicable plan and state ordering requirements

Providers should follow the plan and state requirements regarding which clinician types are authorized to order genetic testing. This policy does not specify a single ordering provider type; follow the member's benefit terms and any applicable state program rules.

Confirm the permitted ordering provider types in the member's plan or state program guidelines before ordering tests.

Note

Kansas-specific counseling and testing requirements

Refer to the Kansas Medical Assistance Program Provider Manual for any pre- or post-test genetic counseling requirements and other Kansas-specific provider rules.

Kansas providers: check the Kansas Medical Assistance Program Provider Manual for counseling and testing requirements.

Member Eligibility and Access

Eligibility criteria for preimplantation genetic testing (PGT) are defined by the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual. This policy does not enumerate top-level eligibility nodes; providers must apply the Kansas manual’s medical necessity criteria when determining member eligibility for PGT-related services.

No additional top-level eligibility requirements are specified in this policy. Follow the Kansas Medical Assistance Program Provider Manual for any family history, prior testing, or other eligibility conditions required to establish medical necessity for PGT.

Key Terms and Test Descriptions

Preimplantation genetic assessment / testing (PGT) — analysis scope and codes

DefinitionAnalysis of embryonic DNA (trophectoderm or blastomere) for aneuploidy, structural rearrangements, mitochondrial DNA score, and targeted familial variant analysis as described by codes 0254U, 0552U-0555U and related CPT/HCPCS codes.

Representative proprietary codes0254U: analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy and a mitochondrial DNA score; 0552U–0555U: PGT analyses for known familial variants, structural rearrangements, ploidy, and quality control, per embryo tested.

Related cytogenomic/unlisted codes81228, 81229, 81349 (cytogenomic analyses); 81479 (unlisted molecular pathology procedure).

Specimen typesTrophectoderm biopsy or blastomere biopsy of embryo prior to transfer; per-embryo reporting described in code definitions.

OpenPayer