Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (fetal chromosomal aneuploidy) for evaluation of the enrollee who was undergoing prenatal care. Findings:  The physician reviewer found that There is a lack of support in the medical literature for the services at issue. The American College of Obstetrics and Gynecology (ACOG) in conjunction with the Society for Maternal-Fetal Medicine recently (July 2015) addressed the issue of the use of cell free DNA testing, given the performance of conventional screening methods, the limitations of cell free DNA screening performance, and the limited data on cost effectiveness in the low risk obstetrical population, conventional screening methods remain the most appropriate choice for first line screening for most women in the general obstetric population. The chart does indicate that the patient had first trimester nuchal translucency (NT) and serum markers testing. However, no results were noted in the chart. It does not appear that the NT first trimester testing was abnormal. The patient had an early pregnancy loss during her second pregnancy, however; this does not place her in a high risk category. Another high risk group is women who will be 35 years of age or older at the time of delivery with an abnormal first trimester NT testing, or second trimester quad screen testing, or an abnormal fetal sonogram finding.  These risk factors were not present for this patient. The American College of Obstetricians and Gynecologists Committee (ACOG) does state that this type of genetic testing is a very rapidly evolving area of pregnancy care. Currently, however, it is hard to say whether noninvasive prenatal testing (NIPT) on all populations will be the new paradigm. Nevertheless, at this time, ACOG has not recommended that patients universally be offered NIPT testing in the low risk setting. For these reasons, the gene test (fetal chromosomal aneuploidy) was not likely to have been more efficacious in evaluating this patients medical condition. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.