Aetna considers genetic counseling in connection with pregnancy management medically necessary for evaluation of any of the following:
Couples who are closely related genetically (consanguinity, incest); or
Familial cancer disorders; or
Individuals from ethnic groups recognized to be at increased risk for specific genetic disorders (e.g., African Americans for sickle cell anemia, Ashkenazi [eastern European] Jews for Tay-Sachs disease); or
Infertility cases where either parent is known to have a chromosomal abnormality; or
Individuals with primary amenorrhea, azospermia, abnormal sexual development or failure in developing secondary sexual characteristics; or
Mother, known, or presumed carrier of an X-linked recessive disorder; or
One or both parents are known carriers of an autosomal recessive disorder; or
Parents of a child born with a genetic disorder, birth defect, inborn error of metabolism or chromosome abnormality; or
Parents of a child with mental retardation, autism, developmental delays, or learning disabilities; or
Pregnant women who, based on prenatal ultrasound tests or an abnormal multiple marker screening test, maternal serum alpha-fetoprotein (AFP) test, test for sickle cell anemia, or tests for other genetic abnormalities have been told their pregnancy may be at increased risk for complications or birth defects; or
Pregnant women with maternal age 35 years or greater at delivery; or
Pregnant women, or women planning pregnancy, exposed to potentially teratogenic, mutagenic or carcinogenic agents (i.e., chemicals, drugs, infections, radiation); or
Previous unexplained stillbirth or repeated (3 or more; 2 or more among infertile couples) first trimester miscarriages, where there is suspicion of parental or fetal chromosome abnormalities; or
When contemplating pregnancy, either parent affected with an autosomal dominant disorder.
Note: Genetic counseling for pregnancy management may not be covered under plans that exclude family planning benefits. Please check benefit plan descriptions for details.
Aetna considers appropriate genetic counseling unrelated to pregnancy medically necessary for consideration of, or provided in conjunction with, medically necessary genetic testing, and in accordance with the guidelines of the American College of Medical Genetics (ACMG).
Aetna considers genetic counseling experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established.
Genetic counseling is a process of communication between patients and trained professionals intended to provide patients who have a genetic disease, or risk of such a disease, with information about their condition and its effect on their family. This allows patients and their families to make informed reproductive and other medical decisions. The counselor will evaluate medical problems or risks present in a family, analyze and explain inheritance patterns of any disorders found, provide information about management and treatment of these disorders, and discuss available options with the family or individual.
According to the American College of Medical Genetics, an important issue in genetic testing is defining the scope of informed consent. The obligation to counsel and obtain consent is inherent in the clinician-patient and investigator-subject relationships. In the case of most genetic tests, the patient or subject should be informed that the test might yield information regarding a carrier or disease state that requires difficult choices regarding their current or future health, insurance coverage, career, marriage, or reproductive options. The objective of informed consent is to preserve the individual's right to decide whether to have a genetic test. This right includes the right of refusal should the individual decide the potential harm outweighs the potential benefits.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria is met:
96040
Other CPT codes related to the CPB:
82106
HCPCS codes covered if selection criteria are met:
S0265
Genetic counseling, under physician supervision, each 15 minutes
ICD-9 codes covered if selection criteria are met:
153.0 - 153.9
Malignant neoplasm of colon [hereditary nonpolyposis colorectal cancer (HNPCC)] [when contemplating pregnancy, either parent affected with an autosomal dominant disorder]
237.71
Neurofibromatosis, Type 1 [von Recklinghausen's disease] [when contemplating pregnancy, either parent affected with an autosomal dominant disorder]
238.4
Polycythemia vera [Osler's disease] [when contemplating pregnancy, either parent affected with an autosomal dominant disorder]
256.39
Other ovarian failure [primary]
256.8
Other ovarian dysfunction [amenorrhea due to ovarian dysfunction]
259.0 - 259.1
Delay in sexual development and puberty and precocious sexual development and puberty, not elsewhere classified [abnormal sexual development or failure in developing secondary sexual characteristics]
277.00 - 277.09
Cystic fibrosis [infertility cases where either parent is known to have a chromosomal abnormality]
282.41 - 282.49
Sickle-cell thalassemia [infertility cases where either parent is known to have a chromosomal abnormality]
282.5
Sickle-cell trait [one or both parents are known carriers of an autosomal recessive disorder]
282.60 - 282.69
Sickle-cell disease [infertility cases where either parent is known to have a chromosomal abnormality]
299.00 - 299.01
Autistic disorder [infertility cases where either parent is known to have a chromosomal abnormality]
307.23
Tourette's disorder [when contemplating pregnancy, either parent affected with an autosomal dominant disorder]
317 - 319
Mental retardation [infertility cases where either parent is known to have a chromosomal abnormality]
330.1
Cerebral lipidoses [Tay-Sachs disease] [infertility cases where either parent is known to have a chromosomal abnormality]
333.0
Other degenerative diseases of the basal ganglia [Shy-Drager]
333.4
Huntington's chorea [when contemplating pregnancy, either parent affected with an autosomal dominant disorder]
334.8
Other spinocerebellar diseases [Machado-Joseph disease] [when contemplating pregnancy, either parent affected with an autosomal dominant disorder]
335.11
Kugelberg-Welander disease [familial spinal muscular atrophy] [infertility cases where either parent is known to have a chromosomal abnormality]
387.0 - 387.9
Otosclerosis [when contemplating pregnancy, either parent affected with an autosomal dominant disorder]
446.1
Acute febrile mucocutaneous lymph node syndrome [MCLS] [when contemplating pregnancy, either parent affected with an autosomal dominant disorder]
606.0 - 606.9
Infertility, male [infertility cases where either parent is known to have a chromosomal abnormality]
626.0
Absence of menstruation [amenorrhea]
628.0 - 628.9
Infertility, female [infertility cases where either parent is known to have a chromosomal abnormality]
647.00 - 647.94
Infectious and parasitic conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium [pregnant women exposed to potentially teratogenic, mutagenic or carcinogenic agents]
655.00 - 655.93
Known or suspected fetal abnormality affecting management of mother [pregnant women who, based on prenatal ultrasound tests or an abnormal multiple marker screening test, maternal serum alpha-fetoprotein (AFP) test, test for sickle cell anemia, or tests for other genetic abnormalities have been told their pregnancy may be at increased risk for complications or birth defects] [pregnant women exposed to potentially teratogenic, mutagenic or carcinogenic agents]
659.50 - 659.63
Elderly primagravida or elderly multigravida [pregnant women with maternal age 35 years or greater at delivery]
753.13
Polycystic kidney, autosomal dominant [infertility cases where either parent is known to have a chromosomal abnormality] [when contemplating pregnancy, either parent affected with an autosomal dominant disorder]
753.14
Polycystic kidney, autosomal recessive [infertility cases where either parent is known to have a chromosomal abnormality] [one or both parents are known carriers of an autosomal recessive disorder]
756.4
Chondrodystrophy [achondroplasia] [when contemplating pregnancy, either parent affected with an autosomal dominant disorder]
758.0 - 759.9
Chromosomal anomalies and other and unspecified congenital anomalies [infertility cases where either parent is known to have a chromosomal abnormality]
796.5
Abnormal finding on antenatal screening [pregnant women who, based on prenatal ultrasound tests or an abnormal multiple marker screening test, maternal serum alpha-fetoprotein (AFP) test, test for sickle cell anemia, or tests for other genetic abnormalities have been told their pregnancy may be at increased risk for complications or birth defects]
990
Effects of radiation, unspecified [pregnant women, or women planning pregnancy, exposed to potentially teratogenic, mutagenic or carcinogenic agents]
989.0 - 989.9
Toxic effect of other substances, chiefly nonmedicinal as to source [pregnant women or women planning pregnancy exposed to potentially teratogenic, mutagenic or carcinogenic agents]
995.20 - 995.29
Other and unspecified adverse effect of drug, medicinal and biological substance [pregnant women or women planning pregnancy exposed to potentially teratogenic, mutagenic or carcinogenic agents]
V10.0 - V10.9
Personal history of malignant neoplasm [familial cancer disorders]
V13.29
Personal history of other genital system and obstetric disorders [previous unexplained stillbirth or repeated (three or more; two or more among infertile couples) first trimester miscarriages, where there is suspicion of parental or fetal chromosome abnormalities]
V13.62 - V13.68
Personal history of congenital malformations [infertility cases where either parent is known to have a chromosomal abnormality]
V13.69
Personal history of other congenital malformations [infertility cases where either parent is known to have a chromosomal abnormality]
V13.7
Personal history of perinatal problems [previous unexplained stillbirth or repeated (three or more; two or more among infertile couples) first trimester miscarriages, where there is suspicion of parental or fetal chromosome abnormalities]
V16.0 - V16.9
Family history of malignant neoplasm [familial cancer disorders]
V18.4
Family history of mental retardation [parents of a child with mental retardation]
V18.61
Family history of polycystic kidney disease [when contemplating pregnancy, either parent affected with an autosomal dominant disorder] [one or both parents are known carriers of an autosomal recessive disorder]
V18.9
Family history of genetic disease carrier [mother, known, or presumed carrier of an X-linked recessive disorder] [one or both parents are known carriers of an autosomal recessive disorder]
V19.5
Family history of congenital anomalies [parents of a child born with a genetic disorder, birth defect, inborn error of metabolism or chromosome abnormality]
V19.7
Family history of consanguinity [couples who are closely related genetically (consanguinity, incest)]
V83.81
Cystic fibrosis gene carrier [one or both parents are known carriers of an autosomal recessive disorder]
V83.89
Other genetic carrier status [one or both parents are known carriers of an autosomal recessive disorder]
V84.01 - V84.09
Genetic susceptibility to malignant neoplasm [familial cancer disorders] [individuals from ethnic groups recognized to be at increased risk for specific genetic disorders (e.g., African-Americans for sickle cell anemia, Ashkenazi (eastern European) Jews for Tay-Sachs disease)]
V84.8
Genetic susceptibility to other disease [individuals from ethnic groups recognized to be at increased risk for specific genetic disorders (e.g., African-Americans for sickle cell anemia, Ashkenazi (eastern European) Jews for Tay-Sachs disease)]
Other ICD-9 codes related to the CPB:
315.0 - 315.9
Specific delays in development [parents of a child with developmental delays or learning disabilities]
783.40
Lack of normal physiological development, unspecified [parents of a child with developmental delays or learning disabilities]
V26.31
Testing for genetic disease carrier status [in conjunction with medically necessary genetic testing, and in accordance with the guidelines of the American College of Medical Genetics (ACMG)]
V26.32
Other genetic testing of female [in conjunction with medically necessary genetic testing, and in accordance with the guidelines of the American College of Medical Genetics (ACMG)]
V26.33
Genetic counseling [see medical necessity criteria]
The above policy is based on the following references:
Schneider KA. Genetic counseling for BRCA1/BRCA2 testing. Genet Test. 1997;1(2):91-98.
Richards MP. Genetic counseling for those with a family history of breast or ovarian cancer--current practice and ethical issues. Acta Oncol. 1999;38(5):559-565.
Doherty RA. National Institutes of Health consensus development conference statement on genetic testing for cystic fibrosis. J Med Screen. 1997;4(4):179-180.
Lindblom A, Nordenskjold M. Hereditary cancer. Acta Oncol. 1999;38(4):439-447.
Peshkin BN, Lerman C. Genetic counselling for hereditary breast cancer. Lancet. 1999;353(9171):2176-2177.
Walsh A. Presymptomatic testing for Huntington's disease: The role of genetic counseling. Med Health R I. 1999;82(5):168-170.
Rose P, Humm E, Hey K, et al. Family history taking and genetic counselling in primary care. Fam Pract. 1999;16(1):78-83.
Miller R. Counselling about diagnosis and inheritance of genetic bleeding disorders: Haemophilia A and B. Haemophilia. 1999;5(2):77-83.
Lynch HT, Watson P, Tinley S, et al. An update on DNA-based BRCA1/BRCA2 genetic counseling in hereditary breast cancer. Cancer Genet Cytogenet. 1999;109(2):91-98.
American College of Medical Genetics (ACMG). Statement on Guidance for Genetic Counseling in Advanced Paternal Age. Bethesda, MD: ACMG; 1996. Available at: http://www.acmg.net/resources/policies/pol-016.asp. Accessed February 28, 2005.
American Society of Human Genetics Board of Directors, American College of Medical Genetics Board of Directors. Points to consider: Ethical, legal, and psychosocial implications of genetic testing in children and adolescents. Am J Hum Genet. 1995;(57):1233-1241.
Section on Hematology/Oncology Committee on Genetics; American Academy of Pediatrics. Health supervision for children with sickle cell disease. Pediatrics. 2002;109(3):526-535.
Olopade OI, Fackenthal JD, Dunston G, e al. Breast cancer genetics in African Americans. Cancer. 2003;97(1 Suppl):236-245.
McIntosh N, Gane LW, McConkie-Rosell A, Bennett RL. Genetic counseling for fragile X syndrome: Recommendations of the National Society of Genetic Counselors. J Genet Counsel. 2000;9(4):303-325.
Bennett RL, Motulsky AG, Bittles A, et al. Genetic counseling and screening of consanguineous couples and their offspring: Recommendations of the National Society of Genetic Counselors. J Genet Counsel. 2002;11(2):97-119.
Bennett RL, Hart KA, O'Rourke E, et al. Fabry disease in genetic counseling practice: Recommendations of the National Society of Genetic Counselors. J Genet Counsel. 2002;11(2):121-146.
Hampel H, Sweet K, Westman JA, et al. Referral for cancer genetics consultation: A review and compilation of risk assessment criteria. J Med Genet. 2004;41(2):81-91.
American Society for Reproductive Medicine (ASRM) and Society for Reproductive Endocrinology and Infertility (SREI). Information on commonly asked questions about genetic evaluation and counseling for infertile couples. A Practice Committee Report. Educational Bulletin. Birmingham, AL: ASRM; February 2002.
Trepanier A, Ahrens M, McKinnon W, et al. Genetic cancer risk assessment and counseling: Recommendations of the national society of genetic counselors. J Genet Couns. 2004;13(2):83-114.
Lips CJ, Hoppener JW, Van Nesselrooij BP, Van der Luijt RB. Counselling in multiple endocrine neoplasia syndromes: From individual experience to general guidelines. J Intern Med. 2005;257(1):69-77.
Braithwaite D, Emery J, Walter F, et al. Psychological impact of genetic counseling for familial cancer: A systematic review and meta-analysis. J Natl Cancer Inst. 2004;96(2):122-133.
Wilson BJ, Torrance N, Mollison J, et al. Improving the referral process for familial breast cancer genetic counselling: Findings of three randomised controlled trials of two interventions. Health Technol Assess. 2005;9(3):1-140.
Langfelder-Schwind E, Kloza E, Sugarman E, et al. Cystic fibrosis prenatal screening in genetic counseling practice: Recommendations of the National Society of Genetic Counselors. J Genet Couns. 2005;14(1):1-15.
Laurino MY, Bennett RL, Saraiya DS, et al. Genetic evaluation and counseling of couples with recurrent miscarriage: Recommendations of the National Society of Genetic Counselors. J Genet Couns. 2005;14(3):165-181.
Braithwaite D, Emery J, Walter F, et al. Psychological impact of genetic counseling for familial cancer: A systematic review and meta-analysis. Fam Cancer. 2006;5(1):61-75.
American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetrics. ACOG Practice Bulletin No. 78: Hemoglobinopathies in pregnancy. Obstet Gynecol. 2007;109(1):229-237.
Berliner JL, Fay AM; Practice Issues Subcommittee of the National Society of Genetic Counselors' Familial Cancer Risk Counseling Special Interest Group. Risk assessment and genetic counseling for hereditary breast and ovarian cancer: Recommendations of the National Society of Genetic Counselors. J Genet Couns. 2007;16(3):241-260.
Radtke HB, Sebold CD, Allison C, et al. Neurofibromatosis type 1 in genetic counseling practice: Recommendations of the National Society of Genetic Counselors. J Genet Couns. 2007;16(4):387-407.
Vig HS, Armstrong J, Egleston BL, et al. Cancer genetic risk assessment and referral patterns in primary care. Genet Test Mol Biomarkers. 2009;13(6):735-741.
Sutphen R, Davila B, Shappell H, et al. Real world experience with cancer genetic counseling via telephone. Fam Cancer. 2010;9(4):681-689.
Baars HF, Christiaans I, de Nijs PT, et al. Hypertrophic cardiomyopathy: DNA diagnosis, genetic counselling and the risk of sudden cardiac death. Ned Tijdschr Geneeskd. 2010;154:A698.
Stoffel EM, Chittenden A. Genetic testing for hereditary colorectal cancer: Challenges in identifying, counseling, and managing high-risk patients. Gastroenterology. 2010;139(5):1436-1441.
Speicher MR, Geigl JB, Tomlinson IP. Effect of genome-wide association studies, direct-to-consumer genetic testing, and high-speed sequencing technologies on predictive genetic counselling for cancer risk. Lancet Oncol. 2010;11(9):890-898.
Riley BD, Culver JO, Skrzynia C, et al. Essential elements of genetic cancer risk assessment, counseling, and testing: Updated recommendations of the National Society of Genetic Counselors. J Genet Couns 2012;21(2):151-161.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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