CurrentUnitedHealthcarePolicy CSO85KS.02

DNA-based noninvasive prenatal tests of fetal aneuploidy (Kansas)

UnitedHealthcare medical policy (Kansas only) referencing Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for medical necessity clinical coverage criteria for DNA-based noninvasive prenatal tests (NIPT) of fetal aneuploidy. Provides applicable procedure codes and references; does not itself list detailed medical necessity criteria but defers to the Kansas Manual and InterQual.

Policy Summary

PayerUnitedHealthcare

PolicyDNA-based noninvasive prenatal tests of fetal aneuploidy (Kansas)

Policy CodePolicy CSO85KS.02

Change TypeRevised (codes updatedselect CPTs removed)

Effective DateSep 1, 2025

Next Review Date

Key ActionProviders must refer to and document adherence to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for medical necessity criteria for DNA-based NIPT.

SourceLink

POLICY UPDATE CHANGES

Applicable Codes updated and CPT codes 0327U, 81420, and 81507 removed.

7Procedure codes listed

YesMaterial change

Coverage Summary

This UnitedHealthcare Medical Policy (Policy Number: CSO85KS.02) is informational and applies only to the state of Kansas. It references the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for medical necessity clinical coverage criteria for DNA-based noninvasive prenatal tests (NIPT) of fetal aneuploidy and provides applicable procedure codes and supporting information. Effective date: September 1, 2025. Last review: September 1, 2025.

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Medical Necessity / Coverage Rationale

Coverage Rationale

Policy directs readers to external Kansas Medical Assistance Program manual for medical necessity clinical coverage criteria:

This Medical Policy only applies to the state of Kansas.

For medical necessity clinical coverage criteria for DNA-based noninvasive prenatal tests of fetal aneuploidy, refer to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual.

UnitedHealthcare uses InterQual for primary medical/surgical criteria; if InterQual lacks applicable criteria, UnitedHealthcare may use UnitedHealthcare Medical Policies approved by the Kansas Department of Health and Environment.

Applicable Procedure Codes (reference)

Applicable Procedure Codes (reference only)mixed

0060U	Twin zygosity, genomic targeted sequence analysis of chromosome 2, using circulating cell-free fetal DNA in maternal blood.
0488U	Obstetrics (fetal antigen noninvasive prenatal test), cell-free DNA sequence analysis for detection of fetal presence or absence of 1 or more of the Rh, C, alloimmunized pregnancies, reported as selected antigen(s) detected or not detected.
0489U	Obstetrics (single-gene noninvasive prenatal test), cell-free DNA sequence analysis of 1 or more and relative mutation-dosage analysis based on molecular counts to determine fetal inheritance of maternal mutation, algorithm reported as a fetal risk score for the condition (e.g., cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia).
0494U	Red blood cell antigen (fetal RhD gene analysis), next-generation sequencing of circulating cell-free DNA (cfDNA) of blood in pregnant individuals known to be RhD negative, reported as positive or negative.
0536U	Red blood cell antigen (fetal RhD); PCR analysis of exon 4 of RHD gene and housekeeping control gene GAPDH from whole blood in pregnant individuals at 10+ weeks gestation known to be RhD negative, reported as fetal RhD status.
81422	Fetal chromosomal microdeletion(s) genomic sequence analysis (e.g., DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood.
81479	Unlisted molecular pathology procedure.

Provider Actions & Documentation Requirements

Documentation Required

Follow Kansas Medical Assistance Program criteria

Providers must refer to and document adherence to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for medical necessity criteria for DNA-based NIPT; coverage determinations are governed by federal, state, or contractual requirements.

Providers must refer to and document adherence to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for medical necessity criteria for DNA-based NIPT.
Benefit coverage and coverage determinations are governed by federal, state, or contractual requirements and applicable laws.

Documentation Required

Use InterQual or approved UnitedHealthcare policies

When applicable, use InterQual criteria for medical/surgical decisions; if InterQual lacks applicable criteria, use UnitedHealthcare Medical Policies that have been approved by the Kansas Department of Health and Environment.

Use InterQual as the primary source for medical/surgical criteria when applicable.
If InterQual does not have applicable criteria, use UnitedHealthcare Medical Policies approved by the Kansas Department of Health and Environment.

Background & Definitions

Background: This Medical Policy applies only to Kansas and serves as an informational guide; for medical necessity clinical coverage criteria for DNA-based NIPT of fetal aneuploidy, readers must refer to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual. Laboratories that perform DNA-based tests are regulated under CLIA. Information about FDA clearance/approval of nucleic-acid based tests is provided for informational purposes only and is not determinative of coverage.

Policy Summary

PayerUnitedHealthcare

PolicyDNA-based noninvasive prenatal tests of fetal aneuploidy (Kansas)

Policy CodePolicy CSO85KS.02

Change TypeRevised (codes updatedselect CPTs removed)

Effective DateSep 1, 2025

Next Review Date

Key ActionProviders must refer to and document adherence to the Kansas Medical Assistance Program Professional Fee-for-Service Provider Manual for medical necessity criteria for DNA-based NIPT.

SourceLink

On This Page

OpenPayer

DNA-based noninvasive prenatal tests of fetal aneuploidy (Kansas)

Coverage Summary

Medical Necessity / Coverage Rationale

Applicable Procedure Codes (reference)

Provider Actions & Documentation Requirements

Background & Definitions

Revision History