Payer Coverage Overview (2024)

Overview

The table below includes the major national private health plans. As previously noted, many private payers require prior authorization for medically necessary coverage. For a more extensive list of plans, including Medicaid, please visit the website for the Coalition for Access to Prenatal Screening.

United Healthcare¹

NIPT is considered medically necessary in the following circ*mstances:

• Maternal age or oocyte age of 35 years or older at delivery; or
• Fetal ultrasound findings indicating an increased risk of aneuploidy; or
• History of a prior pregnancy with a trisomy; or
• Positive first- or second-trimester screening test results for aneuploidy; or
• Parental balanced Robertsonian translocation with an increased risk of fetal trisomy 13 or trisomy 21; or
• Screening after pre-test counseling from a board-certified genetic counselor or from the prenatal care physician or healthcare professional using Shared Decision-Making (SDM)

UnitedHealthCare requires the following medical information: medical office notes documenting maternal age, history of prior pregnancy with a trisomy (if applicable), history of parental balanced Robertsonian translocation, abnormal first- or second-trimester screening test result, counseling provided by genetic counselor or prenatal provider on the risks and benefits of testing using shared decision making.

Cigna^2,3

According to Cigna’s medical policy document, “Sequencing-based non-invasive prenatal testing (NIPT) (CPT® codes 81420, 81507) to screen for fetal trisomy 13, 18 and 21 is considered medically necessary in a viable, single gestation pregnancy ≥ 10 weeks gestation.” There is no indication that there are restrictions around maternal age or risk of chromosomal abnormality or use of genetic counseling.

Aetna⁴

Based on Aetna’s medical policy document, “Aetna considers noninvasive prenatal testing (NIPT) using measurement of cell-free fetal nucleic acids in maternal blood (e.g., MaterniT21, MaterniT21 PLUS, Verifi Prenatal Test, Harmony Prenatal Test, Panorama Prenatal Test, QNatal Advanced) medically necessary for screening for fetal aneuploidy (trisomy 13, 18 and 21) in all pregnant women. Aetna considers NIPT not medically necessary for pregnant women who have previously had a multiple serum marker screening test with or without fetal nuchal translucency ultrasound that is negative for fetal aneuploidy during the current pregnancy.” There is no indication that there are restrictions around maternal age or risk of chromosomal abnormality or use of genetic counseling.

Molina Healthcare⁵

Non-Invasive Prenatal Testing (NIPT) using maternal cell-free DNA (cfDNA) screening for fetal aneuploidy (trisomy 13, 18, and 21) may be considered medically necessary and authorized when all of the following criteria are met:

• Laboratory is a qualified Molina par provider; and
• Single gestation pregnancy after 10 weeks gestation; and
• Pretest and post-test genetic counseling is performed; and
• ANY the following indications are present: [ONE]
  • maternal age 35 years or older at delivery
  • fetal ultrasonographic findings indicating an increased risk of aneuploidy
  • history of a prior pregnancy with a trisomy
  • positive first or second-trimester standard biomarker screening test
  • either parent has been identified as having a balanced Robertsonian translocation with an increased risk of fetal trisomy 13 or trisomy 21

Centene Corporation⁶

Based on the medical policy document, “cell-free fetal DNA testing is medically necessary when meeting all of the following criteria:

• Patient underwent pretest counseling;
• No documentation that a chromosomal abnormality screening test has been performed in this pregnancy (i.e., sequential serum screening, quad screen, penta screen, and serum integrated, or contingent);
• No documentation of a prior abnormal nuchal translucency screening in current pregnancy;
• Current pregnancy is a singleton or twin gestation;
• At least 10 weeks gestation at the time the blood was drawn."

Anthem⁷

Based on the medical policy document, “noninvasive cell-free fetal DNA-based screening for fetal aneuploidy is considered as an acceptable screening option for fetal aneuploidy (trisomy 13, 18 and 21) in average-risk women carrying a single or twin gestation pregnancy” and is “in accordance with generally accepted standards of medical practice."

"Cell-free fetal DNA-based prenatal testing for fetal sex determination is considered medically necessary for singleton pregnancies at increased risk of a sex (X)-linked condition or congenital adrenal hyperplasia."

Humana⁸

Humana does not cover CPT codes 81420, 81479, or 81507 if used to report any test or any indications other than those listed below in the coverage determination section including, but not be limited to:

• Duplicative or repeat (ie, during the same pregnancy) testing for low fetal fraction or test failure); OR
• Duplicative or repeat NIPS testing for chromosomal abnormalities (eg, multiple marker screening with or without 2D ultrasound for nuchal translucency) has been performed during the current pregnancy; OR
• Expanded testing of microdeletion/microduplication analysis (eg, DiGeorge syndrome, Prader-Willi syndrome) (ie, 81422) (eg, Panorama Plus 22q11.2 deletion, MaterniT21 Plus ESS); OR
• Multiple gestation pregnancy; OR
• Screening for monogenic disorders (eg, beta thalassemia, hemophilia, sickle cell anemia); OR
• Screening for sex chromosome aneuploidies (eg, MaterniT21 PLUS + SCA); OR
• Screening for single gene variants (eg, known familial mutation); OR
• Screening for trisomies other than 13, 18 and 21

¹Cell-Free Fetal DNA Testing. UnitedHealthcare Commercial Medical Policy. 2021. https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/cell-free-fetal-dna-testing.pdf

²Medical Coverage Policy: Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis. Cigna. 2019. https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/mm_0514_coveragepositioncriteria_genetic_testing_repro_carrier_prenatal.pdf.

³Master Precertification List. Cigna. 2021. https://www.cigna.com/static/www-cigna-com/docs/individuals-families/master-precertification-list-for-providers.pdf

⁴Serum and Urine Marker Screening for Fetal Aneuploidy. Aetna. 2021. http://www.aetna.com/cpb/medical/data/400_499/0464.html

⁵Non-Invasive Prenatal Testing (NIPT). Molina Healthcare. 2020. https://www.molinahealthcare.com/providers/wa/medicaid/resource/PDF/MCP-157-Noninvasive-Prenatal-Testing.pdf

⁶Clinical Policy: Cell-free Fetal DNA Testing. Centene Corporation. 2020. https://www.mhsindiana.com/content/dam/centene/policies/clinical-policies/CP.MP.84.pdf

⁷Clinical UM Guideline: Cell-Free Fetal DNA-Based Prenatal Testing. Anthem Blue Cross. 2021. https://www.anthem.com/dam/medpolicies/abc/active/guidelines/gl_pw_e000813.html

⁸Medical Coverage Policy: Noninvasive Prenatal Screening. Humana. 2021. https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298304d031&searchID=ec8e34c7-2e65-47a7-a410-61774b77a27b&dl=1