Does O35.04X1 require prior authorization?

No, O35.04X1 does not require prior authorization (high confidence). Covered without prior authorization.

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`O35.04X1`, Maternal care for (suspected) central nervous system malformation or damage in fetus, encephalocele, fetus 1

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Because of the rapid evolution of genetic testing, the decision to rescreen a patient should be undertaken only with the guidance of a genetics professional who can best assess the incremental benefit of repeat testing for additional mutations.
Carrier screening for a particular condition generally should be performed only once in a person's lifetime and the results should be documented in the patient's health record.
If an individual is found to be a carrier for a specific condition, the individual's reproductive partner should be offered testing in order to receive informed genetic counseling about potential reproductive outcomes.

Counseling before screening should include the possibility of results in the 'no-call' category (indeterminate or uninterpretable results).

Confirmatory CVS or amniocentesis is still needed in pregnancies with a positive [NIPT] result.

Comprehensive patient pretest and posttest genetic counseling from qualified personnel such as a genetic counselor or geneticist regarding the benefits, limitations, and results of chromosomal microarray analysis is essential.

Key Coverage Criteria

Preconception or prenatal carrier testing for an individual who has the capacity and intention to reproduce is considered medically necessary when ANY of the following criteria is met:
There is an identified pathogenic or likely pathogenic variant in a blood relative
EITHER of the following criteria is met: an individual's reproductive partner is a known carrier of a disease-causing pathogenic or likely pathogenic variant in a recessively inherited condition
EITHER of the following criteria is met: a genetic diagnosis has been confirmed in an affected relative, AND the affected relative has not had genetic testing and is unavailable for testing
Preconception or prenatal genetic testing of a prospective parent whose sex assigned at birth is female for Fragile X (i.e., FMR1) pathogenic/likely pathogenic gene variants is considered medically necessary for EITHER of the following indications:
family history of unexplained intellectual disability or developmental delay, or autism in a blood relative

1 Active Policy

CIGNA-0514, Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis

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O35.04X1, Maternal care for (suspected) central nervous system malformation or damage in fetus, encephalocele, fetus 1