Preimplantation Genetic Diagnosis*

Medical Policy: 04.02.02 
Original Effective Date: April 2006 
Reviewed: August 2007 
Revised:  

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

Description: 

Preimplantation genetic diagnosis (PGD) is a procedure used to decrease the chance of a particular genetic condition for which the fetus is specifically at risk by testing a single cell removed from early embryos conceived by in vitro fertilization. Only those embryos determined not to have inherited the mutation in question are transferred to the mother's uterus. PGD has been increasingly used as an adjunct to standard in vitro fertilization (IVF) to detect chromosomal abnormalities, called aneuploidy, arising during egg or embryo development.

Policy: 

Coverage for preimplantation genetic diagnosis is a contract-specific benefit issue. Contact benefits should be verified through Provider Services.

Prior approval is recommended. Submit a prior approval now. 

Preimplantation genetic diagnosis as an adjunct to in vitro fertilization (IVF) may be considered medically necessary in the following patients/couples who are undergoing IVF due to infertility:

  • A history of three failed IVF cycles
  • Maternal age is greater than 35 years
  • One of the partner is known to harbor a balanced translocation


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Procedure Codes and Billing Guidelines: 

  • To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
  • CPT 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos
  • CPT 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos

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Selected References: 

  • Verlinsy Y, Rechitisky S, Sharapova T et al. Preimplantation HLA Testing. JAMA 2004; 291(17)2079-85.
  • Preimplantation Genetic Diagnosis. A Discussion of Challenges, Concerns, and Preliminary Policy Options Related to the Genetic Testing of Human Embryos. The Genetics and Public Policy Center at the Phoebe R. Berman Bioethics Institute, Johns Hopkins University. 2004.
  • Kuliev A, Verlinsky Y. The role of preimplantation genetic diagnosis in women of advanced reproductive age. Curr Opin Obstet Gynecol 2003; 15:233-38.
  • Towner D, Loewy RS. Ethics of preimplantation diagnosis for a woman destined to develop early-onset Alzheimer disease. JAMA 2002; 287(8):1038-40.
  • Gianaroli L, Maglin MC, Ferraretti AP et al. The beneficial effects of preimplantation genetic diagnosis for aneuploidy support extensive clinical application. Reprod Med Online 2005; 10:633-40.
  • Kanavakis E, Traeger-Synodinos J. Preimplantation genetic diagnosis in clinical practice. J Med Genet. 2002; 39(1):6-11.
  • Mastenbroek S, Twisk M, van Echten-Arends J et al. In Vitro Fertilization with Preimplantation Genetic Screening. N Engl J Med. 2007. July 5;357:9-17.

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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:

Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

 

*Prior approval is recommended for this policy.

**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.