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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

January 2014

New Medical Policy: Cell-free Fetal DNA Testing 


Harvard Pilgrim has developed a medical policy for cell-free fetal DNA testing to screen pregnant women for the following fetal aneuploidies: trisomy 21, 18, and 13. This policy went into effect on January 1, 2014.

Under the new policy, Harvard Pilgrim covers medically necessary blood testing for these three types of fetal trisomy, provided it meets the following criteria:

  1. The member is carrying a single gestation; and
  2. The member is considered at high risk for fetal aneuploidy due to ANY of the following:
    • The expectant mother will be 35 years or older at the time of delivery; OR
    • The fetus has ultrasonographic findings that indicate an increased risk of aneuploidy; OR
    • The expectant mother has a history of a prior pregnancy with trisomy; OR
    • The expectant mother has a positive first or second-trimester standard biomarker screening test; OR
    • Either parent has been identified as having a balanced Robertsonian translocation with an increased risk of fetal trisomy 13 or trisomy 21.

Harvard Pilgrim does not provide coverage for cell-free DNA-based prenatal testing for additional chromosomal abnormalities including, but not limited to, other trisomies, aneuploidies, or microdeletions.

When ordering cell-free DNA testing, please coordinate with the member to ensure that the laboratory is in the member’s network. You may refer to the plan-specific provider directory to identify in-network laboratories.

Laboratories that report cell-free fetal DNA testing as a risk score should bill Harvard Pilgrim using claims code 81507, while laboratories that report test results without a risk score should use one of the following claims codes:

81479 — Unlisted molecular pathology procedure
84999 — Unlisted chemistry procedure

To avoid unnecessary denials and/or appeals when filing cell-free DNA testing claims using an unlisted code, submit your claim on paper with the necessary supporting documentation. Please refer to the Unlisted and Unspecified Procedure Codes Payment Policy for information on the supporting documentation required to process a claim.

For more information, please refer to the Cell-free Fetal DNA Testing Medical Policy.

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Richard Weisblatt PhD,
Senior Vice President, Provider Network

Annmarie Dadoly,
Editor

Kristin Edmonston,
Production Coordinator