Anthem Blue Cross Connecticut CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies Form

This document addresses chromosomal microarray analysis (CMA), including array (or microarray) comparative genomic hybridization (aCGH) and single nucleotide polymorphism (SNP) arrays, as a diagnostic tool for congenital anomalies as well as for individuals with unexplained developmental delay (DD), autism spectrum disorder (ASD) or intellectual disability (intellectual developmental delay). This document does not provide clinical indications for karyotyping or fluorescence in situ hybridization (FISH).

For information on prenatal testing for fetal aneuploidies (including fetal sex chromosome aneuploidies), fetal sex determination and microdeletions using cell-free fetal DNA isolated from a maternal blood sample, see CG-GENE-21 Cell-Free Fetal DNA-Based Prenatal Testing.

Clinical Indications

Medically Necessary:

Chromosomal microarray analysis (CMA) is considered medically necessary as a first-line test in the initial postnatal* evaluation of individuals with the following:

1. Multiple anomalies not specific to a well-delineated genetic syndrome; or
2. Apparently non-syndromic developmental delay/intellectual disability; or
3. Autism spectrum disorders.

As an alternative to fetal karyotyping, CMA is considered medically necessary for the evaluation of a fetus for ANY of the following:

1. Abnormal fetal anatomic findings which are characteristic of a genetic abnormality; or
2. Fetal demise with congenital anomalies; or
3. In individuals with a structurally normal fetus undergoing invasive prenatal diagnostic testing; or
4. The individual is considered at high risk for fetal aneuploidy due to ANY of the following:
   1. The expectant mother will be 35 years of age or older at the time of delivery; or
   2. The expectant mother has a history of a prior pregnancy with a trisomy; or
   3. The expectant mother has a positive first or second-trimester standard biomarker screening test.

* In this document, the term “postnatal” is not specifically defined in terms of a time frame. The intent is that CMA be done during the initial evaluation once a problem is detected. This means that sometimes, the test may not be done until a number of years after birth.

Not Medically Necessary:

Chromosomal microarray analysis (CMA) is considered not medically necessary for all indications when the above criteria are not met.