Comparative Genomic Hybridization (CGH) (CPB 0787, reviewed 2025-11-19)
Summary
Aetna considers comparative genomic hybridization (CGH), also called chromosomal microarray analysis, medically necessary for fetal structural abnormalities detected on fetal ultrasound or fetal MRI, for histologically equivocal Spitzoid melanocytic neoplasms, for initial evaluation of myelodysplastic syndrome when standard cytogenetics cannot be obtained or the karyotype is normal, for pregnant women undergoing invasive prenatal diagnostic testing for any indication, and for fetal tissue analysis in intrauterine fetal death or stillbirth at 20 weeks gestation or greater. Aetna also considers CGH medically necessary for diagnosing genetic abnormalities in children with congenital anomalies, or with intellectual disability, developmental delay or autism spectrum disorder, when the listed criteria are met. CGH is not considered medically necessary when a disorder or syndrome is readily apparent based on clinical evaluation alone, and only one CGH per lifetime is considered medically necessary. Aetna considers CGH experimental, investigational or unproven for indications including detection of balanced rearrangements, diagnosis of melanoma, diagnosis of neurodevelopmental delays, evaluation of primary ovarian insufficiency, evaluation of short stature, evaluation of unexplained epilepsies, evaluation of autoimmune lymphoproliferative syndrome, evaluation of craniosynostosis, and genetic abnormalities in individuals over 18 years of age with congenital anomalies or with autism spectrum disorder or intellectual disability.
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