Clinical Review Criteria Update – Preimplantation Genetic Testing for Monogenic/Single Gene Defects (PGT-M)

Posted on March 30, 2021

Policy Number: UM481POL
Effective Date: 6/1/2021
LOB Affected: Commercial
Policy Type: Medical

Title of Policy changed:

From:  Preimplantation Genetic Testing (PGT) / Preimplantation Genetic Diagnosis (PGD)

To:  Preimplantation Genetic Testing for Monogenic/Single Gene Defects (PGT-M)

Definitions: 

• Eliminated Preimplantation Genetic Diagnosis (PGD)
• Added under Preimplantation Genetic Testing for Aneuploidy (PGTA): Not covered by HNE
• Removed definition of PGT-A
• Added definitions of Autosomal Recessive Disorder; and Autosomal Dominant Disorder

Located Below Medical Criteria Disclaimer:

“Preimplantation Genetic Testing (PGT)/Preimplantation Genetic Diagnosis (PGD) is used in conjunction …”:  Removed the underlined.

• Located Above I., Criteria for Approval

   Added:  “***Any state mandates for genetic testing take precedence over this policy.***”

• I, Criteria for Approval. Section re-worded:

• Added A. (below) followed by 3 criteria:“A., PGT-M may be medically necessary including IVF with/without ICSI including members that are not infertile when the following criteria are met:”

• Added B.:

Added statement followed by 4 criteria

• II.
• Changed PGD to PGTM: “PGTM should only be offered in centers …”
• Added A., MEDICALLY NECESSARY diagnoses included but are not limited to the following:
• III., Required Documentation: Section relabeled from II. to III.
• IV., What is Not Covered:
  A., Changed PGD to PGT-A
• CPT Codes: Added 89398 which is E&I for this policy
• Source/Citation Section: Added 3 sources/citations

Categories: Provider Newsletter