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Medical Policy Revision: Maternal Plasma DNA Test for Fetal Aneuploidy

Effective June 1, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider claims for the provision of non-invasive, prenatal tests (NIPTs) to assess the risk of fetal trisomies in pregnant women.

Based on the guidelines of our revised medical policy, Maternal Plasma DNA Test for Fetal Aneuploidy, CPT® codes 81507 or 81420 submitted on claims for services provided June 1, 2015 and after will be processed as follows:

  • For patients 35 years of age and older, CPT codes 81507 or 81420 will be allowed when submitted on claims that include one or more of the diagnosis codes listed below.
  • For patients less than 35 years of age, claims that include CPT codes 81507 or 81420 and one or more of the diagnosis codes listed below will pend while information required to determine medical appropriateness is requested and reviewed.
  • For patients of any age, CPT codes 81507 or 81420 submitted on claims that include diagnosis codes other than those listed below will be denied as not medically necessary.

ICD-9 diagnosis codes: 655.03, 655.10, 655.13, 655.20, 655.23, 655.80, 655.83, 659.50, 659.53, 659.60, 659.63, 758.0, 758.1, 758.2, 758.4, 758.5, 795.2, 796.5, V23.49, V23.81, V26.33, V23.82, V28.89, V82.79

ICD-10 diagnosis codes: O35.0XX0, O35.1XX0, O35.2XX0, O35.8XX0, O09.511, O09.512, O09.519, O09.521, O09.522, O09.529, Q90.0, Q90.1, Q90.2, Q90.9, Q91.0, Q91.1, Q91.2, Q91.3, Q91.4, Q91.5, Q91.6, Q91.7, Q92.0, Q92.1, Q92.2, Q92.8, Q92.9, Q95.0, R89.8, O28.0, O28.1, O28.2, O28.3, O28.5, O28.8, O28.9, O09.291, O09.292, O09.299, Z31.5, Z36, Z13.79

Review this revised policy in our online Medical Policy Manual.

Unless Horizon BCBSNJ provides written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after June 1, 2015.

CPT® is a registered mark of the American Medical Association.

LabCorp’s InformaSeq Test Detects Common Fetal Trisomies

There are several nonparticipating clinical laboratory providers that offer non-invasive, prenatal tests (NIPTs) to assess the risk of fetal trisomies in pregnant women. However, participating providers are required to refer Horizon BCBSNJ patients, or send their testing samples, to participating clinical laboratory providers.*

We encourage providers to use InformaSeq™, offered through Integrated Genetics, a member of Laboratory Corporation of America’s® Specialty Testing Group, and a leading provider of reproductive genetic testing services.

The use of InformaSeq is consistent with and supported by Horizon BCBSNJ's medical policy, Maternal Plasma DNA Test for Fetal Aneuploidy.

If you have questions, please contact your LabCorp representative.

Laboratory Corporation of America® is a registered mark of Laboratory Corporation of America® Holdings.

InformaSeq is a service mark of Laboratory Corporation of America® Holdings.

* LabCorp is the exclusive in-network clinical laboratory provider for members enrolled in Horizon BCBSNJ managed care and EPO plans.

  • Participating Horizon Managed Care Network physicians and other health care professionals are required to send testing samples and/or refer patients enrolled in Horizon BCBSNJ managed care plans that do not include out-of-network benefits (Horizon HMO, Horizon EPO, etc.) to LabCorp.

    Pathology services provided in a hospital setting to members enrolled in Horizon BCBSNJ managed care plans by a practice that participates in the Horizon Managed Care Network are allowed as an exception to the above-described LabCorp exclusivity requirements.
  • Patients enrolled in Horizon BCBSNJ managed care plans that include out-of-network benefits (Horizon Direct Access, Horizon POS, etc.) use their in-network benefits when you refer them or send their testing samples to LabCorp and their out-of-network benefits when you refer them or send their testing samples to other clinical labs.

    You may only refer Horizon BCBSNJ patients enrolled in managed care plans that include out-of-network benefits (or send their testing samples) to a clinical laboratory other than LabCorp if that patient chooses to use his or her out-of-network benefits, and you, the participating Horizon Managed Care Network physician or other health care professional, follow the requirements outlined in our Out-of-Network Consent Policy.

    Participating Horizon Managed Care Network physicians and other health care professionals who do not comply with our Out-of-Network Consent Policy will be at risk of an audit.

If you have questions about laboratory services or our Out-of-Network Consent Policy, please contact your Horizon BCBSNJ Network Specialist.


 

Published on: February 27, 2015, 08:00 a.m. ET
Last updated on: November 24, 2020, 23:29 p.m. ET