Invasive Prenatal Diagnosis of Genetic Diseases — CPB 0358 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0358 governing invasive prenatal diagnosis of genetic diseases, effective September 26, 2025. Billing teams handling CPT codes 59000, 59012, 59015, 89290, 89291, and a broad set of molecular cytogenetics codes need to review selection criteria before submitting claims.

This update to the Aetna invasive prenatal diagnosis coverage policy touches 61 CPT codes and 19 HCPCS codes. CPB 0358 Aetna's longest-standing prenatal genetics policy draws a sharp line between covered preimplantation genetic testing and procedures Aetna classifies as not covered for listed indications, including several newer proprietary assays coded under 0254U, 0396U, 0552U, 0553U, 0554U, and 0555U. If your practice or lab bills for prenatal genetic testing under any Aetna commercial plan, this change deserves your attention before September 26, 2025.

Quick-Reference Table

Aetna Invasive Prenatal Diagnosis Coverage Criteria and Medical Necessity Requirements 2025

The Aetna invasive prenatal diagnosis coverage policy covers three core procedure categories when medical necessity criteria are met: chorionic villus sampling (CVS, CPT 59015), genetic amniocentesis (CPT 59000), and percutaneous umbilical blood sampling or cordocentesis (CPT 59012). These are covered for fetal chromosomal abnormality diagnosis. No unusual twists there.

Preimplantation genetic testing for monogenic disorders (PGT-M, formerly called PGD) billed with CPT 89290 or 89291 carries the longest criteria list in the policy. All six of the following must be true before Aetna considers PGT-M medically necessary:

That last criterion — "clinically significant morbidity or disability" — is the one most likely to generate a claim denial if documentation is thin. Make sure the referring provider's notes explicitly support that language.

Fragile X syndrome gets a specific carve-out. PGT-M for Fragile X (billed with CPT 81243 or 81244) meets medical necessity criteria only when one parent carries more than 55 triplet repeats of the FMR1 gene. Document the repeat count explicitly in the clinical record. Without it, expect a denial.

Preimplantation genetic testing for structural rearrangements (PGT-SR) is separately covered when one reproductive partner carries a known balanced translocation or inversion. CPT 89290 and 89291 apply here as well.

Conventional cytogenetic analysis and quantitative fluorescent polymerase chain reaction (QF-PCR) are covered to detect trisomies in chromosomes 13, 18, 21, X, or Y when testing is done solely because of increased aneuploidy risk. Both methods are covered in all prenatal cases referred for fetal ultrasound abnormality — including increased nuchal translucency greater than 3.5 mm — or a familial chromosomal rearrangement. Cytogenetic follow-up of QF-PCR findings for trisomy 13 and 21 is also covered to rule out inherited Robertsonian translocations.

Prior authorization is not explicitly called out as a separate requirement in the published CPB 0358 text, but Aetna's standard process for genetic testing billing guidelines routinely requires clinical review. Check the specific plan's prior auth requirements before scheduling — plan-level requirements can differ from the national policy language.

Aetna Prenatal Genetic Testing Exclusions and Non-Covered Indications

This is where the update creates real reimbursement risk. Aetna explicitly classifies several newer proprietary laboratory assays as not covered for the indications listed in CPB 0358.

The codes in the "not covered" bucket are mostly PLA codes — Proprietary Laboratory Analyses — and HLA antibody codes:

The ICSI codes (89280, 89281) are not covered under this CPB at all. If your IVF center bundles fertilization with genetic testing on a single claim, split that carefully. Submitting ICSI codes under CPB 0358 indications will generate a denial.

The whole genome sequencing codes 0335U and 0336U being excluded here is worth noting. Aetna's pattern of excluding WGS from prenatal coverage is consistent with what we've seen in other CPBs. Don't expect that to change anytime soon — the published literature supporting WGS as a prenatal diagnostic tool isn't where Aetna needs it to be for coverage, apparently.

Coverage Indications at a Glance

Aetna Prenatal Genetic Testing Billing Guidelines and Action Items 2025

1. Audit every active PLA code in your charge master against this policy before September 26, 2025.
If you bill 0254U, 0335U, 0336U, 0396U, 0552U, 0553U, 0554U, or 0555U for Aetna members, those claims will not be covered under CPB 0358. Pull your last 90 days of claims and identify any of those codes billed to Aetna commercial plans.

2. Verify that PGT-M claims include documentation supporting all six medical necessity criteria.
Missing even one — especially "clinically significant morbidity or disability" or "eliminates need for subsequent amniocentesis/CVS" — gives Aetna a clean denial path. Work with your ordering providers to build a documentation template that hits every criterion.

3. Separate ICSI codes from genetic testing claims.
CPT 89280 and 89281 are not covered under this CPB. If your IVF center submits these on the same claim as covered genetic testing codes like 89290 or 89291, the entire claim is at risk. Bill ICSI procedures under the applicable fertility benefit separately.

4. For Fragile X PGT-M claims using CPT 81243 or 81244, document the repeat count explicitly.
"Known carrier" is not enough. The policy requires documentation of more than 55 triplet repeats of the FMR1 gene. If the lab report doesn't include that number, get it into the clinical notes before the claim goes out.

5. Check plan-level prior authorization requirements for all genetic testing codes.
The CPB doesn't call out prior auth requirements explicitly, but Aetna plan administrators routinely apply prior auth to CPT 89290, 89291, and the molecular cytogenetics range (88271–88299). Call Aetna provider services or check the NaviMedix portal before September 26, 2025 to confirm current prior auth thresholds for your patient population.

6. Review QF-PCR claims for proper pairing with cytogenetic codes.
When testing is referred for fetal ultrasound abnormality or nuchal translucency greater than 3.5 mm, Aetna covers both conventional cytogenetics and QF-PCR. Bill both. Leaving either off the claim leaves reimbursement on the table.

7. Talk to your compliance officer if you're unsure how this applies to your specific payer mix.
CPB 0358 applies to Aetna commercial plans. Self-funded plans administered by Aetna may follow different coverage rules. If you see Aetna-administered plans in your payer mix that aren't standard commercial contracts, loop in your compliance officer before the September 26, 2025 effective date.

CPT, HCPCS, and ICD-10 Codes for Invasive Prenatal Diagnosis Under CPB 0358

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered CPT Codes (For Indications Listed in CPB 0358)