Information in the [brackets] below has been added for clarification purposes.  &nbspCodes requiring a 7th character are represented by “+”:

CPT codes covered if selection criteria are met:

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 81420 Fetal chromosomal aneuploidy (eg, 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 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 81508 – 81509 Fetal congenital abnormalities, biochemical assays two or three proteins (PAPP-A, hCG [any form], or DIA), utilizing maternal serum, algorithm reported as a risk score 81510 – 81512 Fetal congenital abnormalities, biochemical assays analytes (AFP, uE3, hCG [any form], DIA), utilizing maternal serum, algorithm reported as a risk score 82105 Alpha-fetoprotein (AFP); serum 82106     amniotic fluid 82677 Estriol 84702 Gonadotropin, chorionic (hCG); quantitative 84703     qualitative 84704     free beta chain 86336 Inhibin A

CPT codes not covered for indications listed in the CPB:

Evaluation of DSCR4 gene methylation in plasma, measurement of circulating fetal nucleated red blood cells and extra-villous trophoblasts via the “Cell Reveal” system, PreSeek (a prenatal fetal cell-free DNA multi-gene sequencing screen for detecting multiple Mendelian monogenic disorders), measurement of cell-free DNA for screening of micro-duplication syndrome, rare autosomal trisomies and single and multi-gene screening by prenatal cell-free fetal DNA – no specific code 0060U Twin zygosity, genomic targeted sequence analysis of chromosome 2, using circulating cell-free fetal DNA in maternal blood 81422 Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood 83516 Immunoassay for analyte other than infectious agent antibody or infections agent antigen; qualitative or semiquantitative, multiple step method [not covered for anti-Mullerian hormone level for first or second trimester screening for Down syndrome] 83520 Immuoassay, analyte, quantitative; not otherwise specified [not covered for anti-Mullerian hormone level for first or second trimester screening for Down syndrome] 83632 Lactogen, human placental (HPL) human chorionic somatomammotropin 84163 Pregnancy-associated plasma protein-A (PAPPA-A)

ICD-10 codes covered if selection criteria are met:

O09.00 – 099.89
09A.111 – O9A.53 Supervision of high risk pregnancy, edema, proteinuria, and hypertensive disorders in pregnancy, childbirth, and the puerperium, Other maternal disorders predominantly related to pregnancy, Maternal care related to the fetus and amniotic cavity and possible delivery problems, Complications of labor and delivery, Encounter for delivery, Complications predominantly related to the puerperium, Other obstetric conditions, not elsewhere classified Z03.71 – Z03.79
Z33.1, Z33.3
Z34.00 – Z36.9 Encounter for suspected maternal and fetal conditions ruled out, Pregnant state incidental, Pregnancy state, gestational carrier, Encounter for supervision of normal pregnancy, Encounter for antenatal screening of mother, Encounter for other antenatal screening, Encounter for antenatal screening of mother