Cell Free Dna Testing denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary:An enrollee has reimbursement for gene panel testing for evaluation of the enrollee who presented for prenatal care. Findings: The physician reviewer found that The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recommends cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (CPT 81420). Findings: Three physician reviewers found that fetal aneuploidy screening is supported for pregnant patients by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. Cell free DNA testing has been validated as having a high detection rate for fetal chromosomal abnormalities including sex chromosomes. Currently, the non-invasive screening test of choice for aneuploidy is cell free DNA testing. Part of the commercial testing includes an analysis of fetal sex chromosomes. Fetal sex chromosomal abnormalities are common. The rate in the general population is 1:448. Sex chromosome abnormalities such as Turner’s syndrome include significant associated medical morbidities.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fetal DNA testing performed. Findings: The physician reviewer found that the American Congress of Obstetricians and Gynecologists recommend cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. In this case, because the patient’s pregnancy was conceived with donor eggs from a 22-year-old, the aneuploidy risk for this patient with this pregnancy is low.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (fetal sex and/or fetal chromosomal microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in maternal blood).Findings: Two of the three physician reviewers found that the American College of Obstetricians and Gynecologists recommends cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Cell Free Dna Testing, then check the rights and deadlines that apply to your plan.