Preimplantation genetic testing (PGT) encompasses a variety of adjunctive techniques to assisted reproductive procedures, in which embryonic DNA is sampled and genetically analyzed, thus permitting deselection of embryos harboring a genetic defect prior to implantation of the embryo into the uterus. This document addresses the use of preimplantation embryo biopsy and genetic testing for aneuploidies (PGT-A), monogenic disorders (PGT-M) or structural rearrangements (PGT-SR). These procedures may be performed as part of an assisted reproductive procedure (ART). The conditions for which ART may be warranted are addressed in the documents noted below.

Note: For additional information regarding the use of perinatal genetic testing, please see:

• CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
• CG-GENE-13 Genetic Testing for Inherited Diseases
• CG-GENE-21 Cell-Free Fetal DNA-Based Prenatal Testing

Note: For the purposes of this document, the term “genetic testing” refers to direct embryo biopsy.

Note: For the purposes of this document, the term “partners” indicates the individuals from whom the sperm and ova originated. That may include the individual members themselves or a gamete donor.

Note: The use of IVF services is subject to separate Benefit Determination, independent of this position statement. Not all benefit contracts or  certificates include benefits for IVF services, including preimplantation genetic testing (PGT). PGT is only covered when IVF services are covered benefits. Benefit language supersedes this document.

Clinical Indications

Medically Necessary:

1. Preimplantation genetic testing for aneuploidies (PGT-A) by embryo biopsy is considered medically necessary when the following criteria have been met:
   1. PGT-A is being used as a technique to improve the implantation rate of in vitro fertilization (IVF) procedures in infertile couples; and
   2. There is documentation in the clinical record of genetic counseling (see Definitions) as appropriate; and
   3. Either of the following:
      1. A history of at least three prior IVF cycles when there was a failed embryo transfer or egg retrieval without embryos to freeze or transfer; or
      2. There is a history of any aneuploidy in a previous pregnancy.
2. Preimplantation genetic testing for monogenic disorders (PGT-M) is considered medically necessary when the following criteria have been met:
   1. PGT-M is being used to deselect embryos with genetic mutations; and
   2. A specific mutation, or set of mutations, has been identified, that identifies the genetic disorder with a high degree of reliability; and
   3. The genetic disorder is associated with severe disability or has a lethal natural history; and
   4. There is documentation in the clinical record of genetic counseling (see Definitions) as appropriate; and
   5. At LEAST ONE of the following:
      1. Both partners are known carriers of the same autosomal recessive disorder; or
      2. One partner is a known carrier of an autosomal recessive disorder, and the couple have previously produced offspring affected by that disorder; or
      3. One partner is a known carrier of a single gene autosomal dominant disorder; or
      4. One partner is a known carrier of a single gene X-linked disorder.
3. Preimplantation genetic testing for structural chromosomal rearrangements (PGT-SR) is considered medically necessary when the following criteria have been met:
   1. PGT-SR is being used to deselect embryos with genetic mutations; and
   2. There is documentation in the clinical record of genetic counseling (see Definitions) as appropriate; and
   3. At LEAST ONE of the following:
      1. One of the partners is known to harbor a structural chromosomal abnormality; or
      2. Male parent is a carrier of a sex chromosome abnormality.
4. Preimplantation genetic testing when used to determine the sex of an embryo is considered medically necessary when the following criteria have been met:
   1. There is a documented history of an X-linked disorder, such that deselection of an affected embryo can be made on the basis of sex alone; and
   2. There is documentation in the clinical record of genetic counseling (see Definitions) as appropriate.
5. Preimplantation genetic testing is considered medically necessary when used to evaluate human leukocyte antigen (HLA) status alone when the following criteria have been met:
   1. A sibling with a bone marrow disorder requires a hematopoietic cell transplant; and
   2. There is no other source of a compatible donor other than an HLA-matched sibling; and
   3. There is documentation in the clinical record of genetic counseling (see Definitions) as appropriate.

Preimplantation embryo biopsy is considered medically necessary when any of the preimplantation genetic testing criteria above are met.

Not Medically Necessary:

Preimplantation genetic testing is considered not medically necessary for all other indications, including when the criteria above have not been met.

Preimplantation genetic screening, including preimplantation genetic testing for aneuploidy (PGT-A), is considered not medically necessary as an adjunct to IVF, except when specified above (Section A), including but not limited to the following circumstances:

• To identify the presence or absence of conditions for which an embryo has no known risk factors.

Preimplantation embryo biopsy is considered not medically necessary when any of the preimplantation genetic testing criteria above have not been met.