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KMAP BULLETIN: Covered Codes for Fetal Testing

Date: 02/05/18

KMAP GENERAL BULLETIN 18000

Effective with dates of service on and after March 1, 2018, fetal aneuploidy testing codes 81420 and 81507 will be covered for at-risk pregnancies when billed with a covered ICD-10 diagnosis code. Fetal aneuploidy testing will be limited to coverage of one CPT® code per pregnancy (270 days).

DNA-based noninvasive prenatal tests of fetal aneuploidy are proven and medically necessary as screening tools for trisomy 21 (Down syndrome), trisomy 18 (Edwards syndrome) or trisomy 13 (Patau syndrome) in any one of the following circumstances:

  • Maternal age of 35 years or older at delivery
  • Fetal ultrasound findings indicating an increased risk of aneuploidy
  • History of prior pregnancy with trisomy
  • Positive first or second trimester screening test results for aneuploidy
  • Parental balanced Robertsonian translocation with an increased risk of fetal trisomy 13 and 21

DNA-based noninvasive prenatal tests of fetal aneuploidy are unproven and NOT medically necessary for all other indications including, but not limited to, the following:

  • Multiple gestation pregnancies
  • Screening for microdeletions
  • Screening for sex chromosome aneuploidies

Note: The effective date of the policy is March 1, 2018. The implementation of State policy by the KanCare managed care organizations (MCOs) may vary from the date noted in the Kansas Medical Assistance Program (KMAP) bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates, once the policy is implemented.

 

For the changes resulting from this provider bulletin, view the updated Hospital for-Service Provider Manual, Section 8200, page 8-8, and Professional Fee-for-Service 8400, page 8-32.