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0554U prior authorization | Premera Blue Cross of Washington

0554U, Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal (euploidy), monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested These criteria do not imply or guarantee approval., is on the Premera Blue Cross of Washington prior authorization list. Not a coverage or referral decision.

Code
0554U
Description
Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal (euploidy), monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested These criteria do not imply or guarantee approval.
Source
Clinical Review by Code List PBCWA, Pg 112 Original policy

Premera Blue Cross of Washington prior authorization

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