Preimplantation Genetic Testing and Related Services (for Tennessee Only)

Coverage Summary

UnitedHealthcare Tennessee Medicaid/CoverKids policy CS16OTN.L governs coverage and medical necessity for Preimplantation Genetic Testing (PGT). The policy takes a mixed coverage stance: PGT-M and PGT-SR (and HLA typing) are defined as proven and medically necessary under specified parental risk and condition severity criteria, whereas other uses (including routine PGT-A and PGT-P) are considered unproven/not medically necessary. Effective date: July 1, 2025.

Key thresholds and quick facts

State scopeTennessee Medicaid / CoverKids

Effective dateJuly 1, 2025

Policy numberCS16OTN.L

Primary covered PGT types (RPL definition / thresholds)PGT-M and PGT-SR are proven and medically necessary; RPL definition in some studies uses >= 2 spontaneous pregnancy losses

Explicitly excluded/unproven usesDetermining gender without sex-linked risk; PGT-A (aneuploidy screening) for universal use; PGT-P / polygenic risk scores — not clinically supported

Applicable code updatesApplicable CPT/PLA codes updated — added 0552U, 0553U, 0554U, 0555U; full applicable code list included

Evidence directionMixed across PGT modalities (established for PGT-M/PGT-SR; conflicting/insufficient for PGT-A and PGT-P)

Medical‑Necessity Criteria

Medically Necessary Indications (PGT-M and PGT-SR)

Covered when ALL of the following are met:

PGT is proven and medically necessary for HLA typing on an embryo when performed to enable the future child to provide bone marrow or blood to treat an affected sibling.

Medically Necessary: HLA Typing

Covered when ALL of the following are met:

ALL of the following

PGT is being performed for the purpose of human leukocyte antigen (HLA) typing to identify an embryo that could be a donor for an affected sibling
Testing is performed on embryo tissue using an appropriate validated method

Not Medically Necessary / Unproven Indications

PGT is unproven and not medically necessary for all other populations and conditions due to insufficient evidence, including but not limited to:

ANY of the following

Determining gender when the embryo is not at risk for a sex-linked disorder.
Aneuploidy screening (PGT-A).
Predicting risk of polygenic disorders (PGT-P) and/or embryo selection based on polygenic scores (ESPS).

Clinical Conclusions & Evidence Summary

This section summarizes the clinical evidence, systematic reviews, registry and cohort studies, and professional guidance cited in the policy to inform conclusions about safety, effectiveness, and clinical utility of PGT modalities.

Study / Source	Key finding
Mao et al. 2024 meta-analysis	TE biopsy for PGT did not increase defined adverse obstetrical or neonatal outcomes compared to standard IVF/ICSI; authors recommend larger well-designed RCTs
Ginstrom Ernstad et al. 2023 (registry study)	No difference in preterm birth or low birth weight between PGT and IVF/ICSI; higher preterm birth and LBW compared to spontaneous conception; limited by small PGT sample and short follow-up
Hou et al. 2021 meta-analysis	PGT associated with reduced low birth weight and very preterm birth versus IVF/ICSI but increased hypertensive disorders of pregnancy
STAR RCT (Munne et al. 2019)	No significant difference in ongoing pregnancy rate per ET between PGT-A and control overall; subgroup suggested possible benefit for women aged 35–40 years
Systematic reviews/meta-analyses (various 2017–2025)	Conflicting results for PGT-A: some show reduced miscarriage and improved LBR in select groups (advanced maternal age, RPL), others show no benefit or decreased cumulative live birth rate
niPGT-A (Huang et al. 2019b)	Small investigational study reported zero false negatives and higher PPV/specificity versus TE biopsy; requires larger validation studies
PGT-P guidance (ACMG 2024, Hayes 2022, Siermann 2022)	Professional societies recommend against routine clinical use of PGT-P/PRS; insufficient evidence and ethical concerns; advise research settings only
Randomized Controlled Trials (Yan et al. 2021; other RCTs)	Two RCTs showed no benefit of universal PGT-A for improving live birth rate; age and other factors influence outcomes
PGDIS position (mosaicism guidance)	Higher-level mosaicism associated with less favorable outcomes; percentage of mosaicism better predicts outcome than specific chromosomes
Policy update / CPT codes (07/01/2025)	Applicable CPT codes list updated; added 0552U, 0553U, 0554U, and 0555U

Professional society positions and guidance referenced

Professional societiesACMG, ASRM, ACOG, ESHRE/ESHG, PGDIS; joint ASRM/SART statements referenced

ACMG positionACMG (2024) advises PGT-P/PRS only in research settings; notes risks and need for further study

ASRM guidanceASRM (2023, 2024) supports PGT‑M for significant reproductive risk, recommends genetic counseling; advises caution on PGT-A universal use and provides mosaic management guidance

ACOG recommendationsACOG (Committee Opinion 799, 2020 reaffirmed 2023) supports clinical utility of PGT‑M/PGT‑SR and recommends offering prenatal confirmation (CVS/amniocentesis); PGT‑A utility undetermined

Applicable Codes

PGT / Preimplantation genetic assessment (specified CPT/PLA codes)CPT|HCPCS|mixedCovered

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/duplication, mosaicism, and segmental aneuploidy, 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 DNA genomic sequence analysis from embryonic trophectodem for structural rearrangements, aneuploidy, and a mitochondrial DNA score, results reported as normal/balanced (euploid/balanced); unbalanced structural rearrangement; monosomy; trisomy; segmental aneuploidy, or mosaic, per embryo tested.
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, results reported as normal (euploidy), monosomy; trisomy; segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested.
0555U	Reproductive medicine (preimplantation genetic assessment); analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectodem for structural rearrangements, aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal/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.
81228	Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number variants, CGH microarray analysis.
81229	Cytogenomic analysis; interrogation of genomic regions for copy number and SNP variants, CGH microarray analysis.
81349	Cytogenomic analysis; interrogation 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); <= 5 embryos.

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Applicable CPT/HCPCS codes (updated)CPT

0552U
0553U
0554U
0555U

Provider Actions & Billing Implications

Documentation Required

Genetic counseling required

PGT must be ordered after genetic counseling; providers should document that genetic counseling occurred prior to ordering PGT.

Prior Authorization

Prior authorization implication

Policy applies to Tennessee Medicaid and CoverKids and defines medical necessity criteria — providers should obtain applicable preauthorization/benefit determination per state/contractual requirements when submitting claims for PGT services.

Definitions

Definitions (term: definition):

Preimplantation Genetic Testing (PGT): Test performed to analyze DNA from oocytes or embryos for HLA typing or genetic abnormalities, including PGT-M (monogenic), PGT-A (aneuploidy), and PGT-SR (structural rearrangements).

Significant Health Problems or Severe Disability: A disability or impairment that substantially limits major life activities, expected to last at least 12 months or result in death (Federal SSD definition).

PGT-A: Preimplantation genetic testing for aneuploidy (chromosome copy number screening).

PGT-SR: Preimplantation genetic testing for structural rearrangements in parental chromosomes.

PGT-M: Preimplantation genetic testing for monogenic/single-gene disorders.

PGT-HLA: PGT to identify embryos that are HLA-compatible with an existing sick sibling for potential HSCT.

PGT-P: Preimplantation genetic testing using polygenic risk scores to estimate multigenic disease risk.

TE biopsy: Trophectoderm biopsy performed on blastocyst-stage embryos to obtain cells for genetic testing.

PGT-A: Preimplantation Genetic Testing for Aneuploidy.

PGT-M: Preimplantation Genetic Testing for Monogenic (single-gene) disorders.

PGT-SR: Preimplantation Genetic Testing for Structural Rearrangements.

PRS: Polygenic Risk Scores.

Revision History

2025-07-01revisedLatest

Applicable CPT codes list updated; added 0552U, 0553U, 0554U, and 0555U.