Aetna modified CPB 0787 for comparative genomic hybridization (CGH), effective November 21, 2025. Here's what billing teams need to know before submitting claims.
Aetna, a CVS Health company, updated its CGH coverage policy under CPB 0787 in the Aetna system, affecting CPT codes 81228, 81229, 81277, and 81349, plus HCPCS code S3870. This policy governs when chromosomal microarray analysis counts as medically necessary versus experimental — and the line between those two categories is narrow enough that a single missing criterion kills your claim.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Comparative Genomic Hybridization (CGH) |
| Policy Code | CPB 0787 |
| Change Type | Modified |
| Effective Date | November 21, 2025 |
| Impact Level | High |
| Specialties Affected | Medical Genetics, Maternal-Fetal Medicine, Pediatrics, Neurology, Dermatology (Pathology), Hematology/Oncology |
| Key Action | Audit all pending CGH claims against the five covered indications and multi-criteria checklists before submitting |
Aetna Comparative Genomic Hybridization Coverage Criteria and Medical Necessity Requirements 2025
The Aetna CGH coverage policy under CPB 0787 covers CGH testing under five distinct clinical indications. Each one has hard criteria. Miss one, and you're looking at a claim denial.
Indication 1: Fetal structural abnormalities. Aetna covers CGH when a fetus has structural abnormalities detected on ultrasound or MRI. The imaging finding is the trigger — document the finding in the record before ordering.
Indication 2: Spitzoid melanocytic neoplasms. CGH is covered for histologically equivocal Spitz nevus and atypical Spitz tumors. This is a narrow, specific indication. Melanoma diagnosis is explicitly excluded — use ICD-10 codes D22.0–D22.9 here, not C43.x.
Indication 3: Myelodysplastic syndrome (MDS). CGH is medically necessary for initial MDS evaluation in two scenarios. First, when standard cytogenetics with 20 or more metaphases cannot be obtained. Second, when karyotype testing is normal. This is an either/or gateway — document which condition applies.
Indication 4: Invasive prenatal diagnostic testing. Pregnant patients undergoing amniocentesis or chorionic villus sampling qualify for CGH for any indication. The invasive procedure itself is the coverage trigger. Make sure the record documents which invasive procedure was performed.
Indication 5: Fetal tissue analysis for intrauterine death or stillbirth. Aetna covers CGH for analysis of amniotic fluid, placenta, or products of conception in cases of intrauterine fetal death or stillbirth at 20 weeks gestation or greater. Below 20 weeks is excluded — that's structural abnormalities analysis under a different coding path.
CGH for Pediatric Congenital Anomalies
This is where the criteria stack gets complex. Aetna covers CGH for genetic abnormality diagnosis in children with congenital anomalies only when all four of these conditions are met simultaneously:
| # | Covered Indication |
|---|---|
| 1 | The child's presentation is not specific to a well-defined genetic syndrome (if the syndrome is apparent on clinical exam, CGH is not covered) |
| 2 | The child meets at least one of three malformation thresholds: two or more major malformations; OR a single major malformation or multiple minor malformations with a history of intrauterine growth restriction (IUGR) or small for gestational age; OR a single major malformation plus multiple minor malformations |
| 3 | A board-certified or board-eligible Medical Geneticist, Developmental/Behavioral Pediatrician, or Pediatric/Adult Neurologist has evaluated whether CGH is warranted |
| 4 | Test results have the potential to change clinical management |
All four must be present. A specialist evaluation without documented management impact potential won't hold up on audit.
CGH for Intellectual Disability or Autism Spectrum Disorder
For children with DD/ID or ASD — diagnosed per DSM-5 criteria — CGH is covered only when all four of these apply:
| # | Covered Indication |
|---|---|
| 1 | Targeted genetic testing (such as FMR1 gene analysis for Fragile X) was performed when indicated by clinical and family history, and it was negative |
| 2 | The presentation is not specific to a well-defined genetic syndrome |
| 3 | A board-certified or board-eligible Medical Geneticist, Developmental/Behavioral Pediatrician, or Pediatric/Adult Neurologist has evaluated whether CGH is warranted |
| 4 | Results have the potential to change clinical management |
The Fragile X screening requirement is the step that most often trips up prior authorization requests. If the clinical or family history indicates Fragile X is plausible, you need that FMR1 analysis on file — negative — before CGH is approvable.
One more rule that applies across all indications: Aetna covers only one CGH test per lifetime per member. If a member has had a prior CGH under any indication, a second test will not be covered regardless of the clinical scenario.
Aetna CGH Exclusions and Non-Covered Indications
Aetna considers CGH experimental, investigational, or unproven for the following. These will not receive reimbursement under CPB 0787:
| # | Excluded Procedure |
|---|---|
| 1 | Detection of balanced chromosomal rearrangements |
| 2 | Diagnosis of melanoma (C43.x codes — this is a hard exclusion; CGH for equivocal Spitzoid lesions uses D22.x) |
| 3 | Diagnosis of neurodevelopmental delays (separate from the covered DD/ID indication with criteria met) |
| 4 | Evaluation of autoimmune lymphoproliferative syndrome (ALPS) — ICD-10 D89.82 |
The melanoma vs. Spitzoid distinction deserves attention. CGH is covered for histologically equivocal Spitz tumors (D22.x), not for confirming or diagnosing melanoma (C43.x). If a pathology report is ambiguous on which diagnosis is primary, get clarity before billing.
Products of conception in pregnancy losses under 20 weeks gestation — coded with O02.1, O02.81–O02.9, O03.x, or N96 — are also not covered for CGH analysis. The 20-week threshold is firm.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Fetal structural abnormalities on ultrasound or MRI | Covered | 81228, 81229, 81349 | Imaging finding must be documented |
| Spitzoid melanocytic neoplasms (histologically equivocal) | Covered | 81277, D22.0–D22.9 | Equivocal on histology only; melanoma diagnosis excluded |
| MDS, initial evaluation — standard cytogenetics failed or karyotype normal | Covered | 81277, 88264, 88280, D46.0–D46.9 | Document which gateway applies |
| Invasive prenatal testing (amniocentesis or CVS) | Covered | 81228, 81229, 81349, S3870 | Any indication qualifies; document procedure performed |
| Intrauterine fetal death/stillbirth ≥20 weeks | Covered | 81228, 81229, 81349 | Gestational age cutoff is strict |
| Pediatric congenital anomalies (all 4 criteria met) | Covered | 81228, 81229, 0156U, S3870 | Specialist evaluation + management impact required |
| DD/ID or ASD — targeted testing negative, criteria met | Covered | 81228, 81229, 0156U, S3870 | FMR1 testing must be negative first; DSM-5 diagnosis required |
| Melanoma diagnosis | Not Covered / Experimental | C43.x | Experimental per CPB 0787 |
| Balanced chromosomal rearrangement detection | Not Covered / Experimental | — | Insufficient evidence |
| Neurodevelopmental delay diagnosis (no formal DD/ID criteria met) | Not Covered / Experimental | F01.50–F99 range | Separate from covered DD/ID with criteria |
| Autoimmune lymphoproliferative syndrome (ALPS) | Not Covered / Experimental | D89.82 | Excluded per CPB 0787 |
| Products of conception <20 weeks gestation | Not Covered | O02.1, O02.81–O02.9, O03.x, N96 | Gestational age cutoff applies |
Aetna CGH Billing Guidelines and Action Items 2025
The effective date for this policy update is November 21, 2025. If you're submitting CGH claims under Aetna now, these apply immediately.
| # | Action Item |
|---|---|
| 1 | Audit your CGH charge capture for CPT 81228, 81229, 81277, and 81349 today. Pull any claims pending or recently submitted under those codes and verify each one maps to a covered indication with documentation to support it. Claims missing specialist evaluation notes or management impact documentation are denial risks. |
| 2 | Separate your Spitzoid and melanoma claims before billing. If your dermatopathology team uses CGH for skin lesions, confirm the pathology report reflects a histologically equivocal Spitz nevus or atypical Spitz tumor — not a melanoma diagnosis. Recode from D22.x to C43.x only when appropriate, and know that C43.x triggers experimental status under this coverage policy. |
| 3 | Build a prior authorization checklist for DD/ID and ASD cases before ordering CGH. The Fragile X FMR1 testing requirement is real and will surface in prior auth review. Your ordering workflow should confirm FMR1 results are on file, the diagnosis meets DSM-5 criteria, a qualified specialist has documented the evaluation, and management impact is stated — before the test is ordered, not after. |
| 4 | Flag the lifetime limit in your EHR or billing system. One CGH per lifetime is a hard rule. If a patient has a prior CGH claim in their history — regardless of indication — a repeat test will not get covered. Add a check in your pre-authorization workflow. |
| 5 | Confirm gestational age documentation for all prenatal CGH claims. For stillbirth and intrauterine fetal death cases, the record must show 20 weeks or greater. For amniocentesis and CVS cases, document the procedure itself as the coverage trigger. Gestational age below 20 weeks for products of conception analysis is not covered — don't submit it expecting reimbursement. |
| 6 | If you bill HCPCS S3870 for chromosomal microarray in developmental delay or ASD, make sure the claim meets all four DD/ID criteria above. S3870 is covered under CPB 0787 when those criteria are met, but it's a flag code — payers look at it closely. Attach documentation proactively. |
| 7 | Review the specific product names in your order menus. Aetna's billing guidelines under CPB 0787 call out three named tests: the Oligo HD Scan (array CGH), the CombiMatrix DNArray (developmental delay CGH), and FirstStepDX Plus Chromosomal Microarray (buccal swab collection CGH). All three fall under this coverage policy. If your lab orders reference these products by name, map them to CPT 81228, 81229, or 0156U accordingly. |
If you're unsure how these criteria apply to a specific case mix — particularly in pediatric genetics or maternal-fetal medicine — loop in your compliance officer before the November 21, 2025 effective date catches you mid-claim.
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for CGH Under CPB 0787
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 81228 | CPT | Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants |
| 81229 | CPT | Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants and SNP genotyping |
| 81277 | CPT | Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number variants |
| 81349 | CPT | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions |
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| S3870 | HCPCS | Comparative genomic hybridization (CGH) microarray testing for developmental delay, autism spectrum disorder, and/or intellectual disability |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| C43.0–C43.9 | Malignant melanoma of skin (experimental — not covered for CGH) |
| D03.0–D03.9 | Melanoma in situ (experimental) |
| D22.0–D22.9 | Melanocytic nevi — Spitzoid melanocytic neoplasms (covered for equivocal histology) |
| D46.0–D46.9 | Myelodysplastic syndrome (covered for initial evaluation when criteria met) |
| D89.82 | Autoimmune lymphoproliferative syndrome — ALPS (experimental — not covered) |
| E28.310–E28.39 | Primary ovarian failure / primary ovarian insufficiency |
| F01.50–F99 | Mental, behavioral, and neurodevelopmental disorders (not covered for genetic abnormality evaluation without meeting DD/ID criteria) |
| G40.001–G40.919 | Epilepsy and recurrent seizures |
| N96 | Recurrent pregnancy loss (products of conception <20 weeks — not covered) |
| O02.1 | Missed abortion — products of conception <20 weeks (not covered) |
| O02.81–O02.9 | Other abnormal product of conception |
| O03.0–O03.9 | Spontaneous abortion — products of conception <20 weeks (not covered) |
| O09.511–O09.524 | Supervision of elderly primigravida or multigravida |
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