CommercialCoverageMedium impact
Invasive Prenatal Diagnosis of Genetic Diseases (CPB 0358, reviewed 2026-05-22)
Aetna·OB-GYN, Genetics, Pediatrics·Genetic Testing
Effective date
May 22, 2026
We identified it
Aug 19, 2026
Summary
Aetna has updated its invasive prenatal diagnosis policy (CPB 0358) effective 2026-05-22, clarifying medical necessity criteria for genetic testing procedures including CVS, amniocentesis, PUBS, and preimplantation genetic testing (PGT-M, PGT-SR). The policy explicitly designates certain tests as experimental/investigational (including Igenomix and Natera branded tests) and reinforces that PGT-A remains unproven. Billing teams must ensure claims align with specific medical necessity criteria and carrier status requirements.
Action Required
By 2026-05-22: Billing team must update claim submission protocols to require documented verification of specific medical necessity criteria before processing PGT-M/PGD claims. Specifically: (1) Verify that at least one parent is a known carrier of a documented genetic condition (autosomal dominant, autosomal recessive, X-linked, or chromosomal rearrangement) with confirmed mutation identified; (2) Confirm Fragile X cases meet the specific threshold of 55+ triplet repeats for at least one parent; (3) Flag and deny all claims for PGT-A (Smart PGT-A, Smart PGT-A Plus, microarray analysis), Igenomix PGT-M, Igenomix PGT-SR, Natera Spectrum PGT-M, and IriSight Prenatal Analysis as experimental/investigational; (4) Update encounter templates to require providers to document that genetic testing results will directly impact management and that testing eliminates need for subsequent invasive prenatal diagnosis; (5) Implement system rules to deny ICSI for PGT-A creation of embryos. Failure to apply these criteria will result in claim denials. Coordinate with providers in OB-GYN and reproductive medicine departments to ensure compliance with documentation requirements.