Prior Authorization Requests
While ACOG maintains that prior authorization should not be necessary for NIPT screening or diagnostic testing, many health plans are requiring physicians to go through the process. Each plan will require various information. Most plans that require prior authorization also require documentation or attestation of patient counseling and/or a patient counseling plan. Obstetric clinicians should document in the patient record the discussion of prenatal testing with the patient, including discussions and questions that cover:
- Chromosomal disorders
- Review of relevant personal and family history
- Risks, limitations, and benefits of available testing options
- Detection rate for each test
- The concept of residual risk for negative screening results
- Patient preference regarding comprehensive prenatal detection (for diagnostic testing recommendation)
- The screening approach recommended (for patients requesting a screen)
- Treatment plan or additional counseling (if applicable)
The following CPT codes may be helpful for obtaining prior authorization when needed. Codes listed below represent the common aneuploidy panel with or without sex chromosome analysis. If ordering an expanded panel, please ask the performing laboratory if additional CPT codes apply.
Some laboratories may employ a bundled coding system for testing, and health plans may include or exclude certain codes. Please see the health plan coverage for additional information. In general, the codes for NIPT testing are:
- 81420: Fetal chromosomal aneuploidy (e.g., trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21
- 81422: Fetal chromosomal microdeletion(s) genomic sequence analysis (e.g., DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood
- 81479: Unlisted molecular pathology procedure
- 81507: Fetal aneuploidy (trisomy 21, 18 and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy
- 0060U: Twin zygosity, genomic targeted sequence analysis of chromosome 21, using circulating cell-free fetal DNA in maternal blood
- 0168U: Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma without fetal fraction cutoff, algorithm reported as a risk score for each trisomy
Prior Authorization Denials Appeal
It may be necessary to appeal a prior authorization denial if the health plan has not yet updated their coverage to include NIPT testing or cell-free DNA screening for average-risk patients. See our template letter on the following page.
Use the language in the letter as a template to build upon to demonstrate the medical necessity of the NIPT ordered for the relevant patient. Several portions of the letter include spaces to insert information relevant to your specific needs, including contact names, patient/clinical information, and payer information. To accompany your letter, include any copies of the prior authorization denial letter/notification or explanation of benefits that may have been provided directly to the patient indicating why the request was not covered. Additionally, include any other documentation that may be helpful in demonstrating medical necessity or clinical appropriateness. Rationale for denials can be varied and uniquely specific to each circumstance. This letter was designed to be edited to include clinically relevant information that would strengthen the case for appealing the claims denial.
Please note that this letter is not intended to promote changes to private payer’s coverage policies surrounding NIPT. If the payer in question’s coverage policies indicate that NIPT is not medically necessary or is not covered in all circumstances, please refer to the policy advocacy letters.
IMPORTANT: When drafting and sending these letters, please securely send protected health information to avoid any unnecessary breaches of sensitive data.