Current through Register Vol. 24-18, September 15, 2024
(1)
For the purpose of
RCW
48.21.244,
48.44.344, and
48.46.375, the following are
standards of medical necessity for insurers, health care service contractors,
and health maintenance organizations to use when authorizing requests or claims
for prenatal screening or diagnosis without the requirement of a case-by-case
determination:
(a) Hepatitis B surface
antigen (HBsAg) screening for all pregnant persons during the first trimester
of pregnancy and the last trimester of pregnancy if the person is at high risk
for hepatitis B infection.
(b)
Group B strep screening through prenatal vaginorectal cultures at thirty-five
to thirty-seven weeks of gestation. Pregnant persons who are currently
colonized with Group B strep, or who have unknown Group B strep status should
receive intrapartum treatment in accordance with the current standard of
practice in order to reduce risk to the newborn.
(2) For the purpose of
RCW
48.21.244,
48.44.344, and
48.46.375, the following are
standards of medical necessity for insurers, health care service contractors,
and health maintenance organizations to use when authorizing requests or claims
for prenatal screening or diagnosis without the requirement of a case-by-case
determination and including preprocedure and postprocedure genetic counseling:
(a) Maternal serum marker screening for all
pregnant e persons at the beginning of prenatal care if initiated before the
twenty-second completed week of gestation.
(b) Prenatal ultrasonography:
(i) During the first trimester to establish
viability, gestational age, and determine if singleton or multiple births;
and
(ii) During second trimester
for fetal morphology.
(c) Additional prenatal ultrasonography can
be done at any time during a pregnancy if one or more of the following criteria
are met:
(i) A person is undergoing
amniocentesis, chorionic villus sampling, percutaneous umbilical blood
sampling, or fetal tissue biopsy;
(ii) The results of a maternal serum marker
screening or prenatal cell free DNA test indicate an increased risk to the
fetus or pregnancy;
(iii) There is
an increased risk of a congenital abnormality due to:
(A) An environmental exposure;
(B) A medical evaluation indicating the
possibility of polyhydramnios oligohydramnios, or poor or accelerated fetal
growth; or
(C) A personal or family
history of a congenital abnormality that is potentially detectable by prenatal
ultrasound.
(d) Amniocentesis after fourteen weeks of
gestation.
(e) Chorionic villus
sampling between ten and fourteen weeks of gestation.
(f) Fetal diagnostic testing including:
(i) Cytogenetic studies on fetal cells
including chromosome analysis, targeted cytogenomic microarray analysis (CMA),
and fluorescent in-situ hybridization (FISH) for any person undergoing
amniocentesis or chorionic villus sampling; and
(ii) DNA testing, biochemical testing, or
testing for infectious diseases if medically indicated because of an abnormal
ultrasound finding, intrauterine fetal demise, or known family history;
and
(iii) Cytogenomic microarray
analysis in the case of recurrent intrauterine fetal demise.
(g) Prenatal cell free DNA testing
performed after nine weeks of gestation for the detection of aneuploidy
including trisomy 21, 18, 13, or the sex chromosomes if the following criteria
are met:
(i) There is documentation of
preprocedure genetic counseling;
(ii) There is documentation of how
postprocedure genetic counseling will be provided; and
(iii) Testing the sex chromosomes is not
solely for the purposes of determining the sex of the fetus.
(h) Carrier screening at any time
during the pregnancy for:
(i) Recessive or
X-linked conditions if indicated by a positive family history; and
(ii) Any of the following conditions
irrespective of family history:
(A)
Alpha-thalassemia (HBA1/HBA2);
(B)
Beta-thalassemia;
(C) Bloom
syndrome;
(D) Canavan
disease;
(E) Cystic
fibrosis;
(F) Familial dysautonomia
(IKBKAP);
(G) Fanconi anemia type C
(FANCC);
(H) Gaucher disease
(GBA);
(I) Mucolipidosis IV
(MCOLN1); or
(J) Niemann-Pick
disease (SMPD1);
(K) Sickle cell
disease;
(L) Spinal muscular
atrophy (SMN1);
(M) Tay-Sachs
disease (HEXA);
(N) Fragile-X
Syndrome.
(iii) Carrier
screening under (h)(i) and (ii) of this subsection may be limited to once per
lifetime.
(i) Molecular
genetic or cytogenetic testing of parents to allow for definitive fetal
testing, or parental testing to better inform results that are suggestive of,
but do not identify a unifying diagnosis and when the results of the parental
testing will be used to guide treatment, reproductive decisions, or care
planning that would not otherwise be made.
(3) The following procedures are for use by
insurers, health service contractors, and health maintenance organizations in
determining medical necessity on a case-by-case basis to use when authorizing
requests for claims for prenatal screening and diagnosis:
(a) Percutaneous umbilical cord blood
sampling after fifteen weeks of gestation if one or more of the following
criteria are met:
(i) A medical evaluation
indicates rapid or specific sub-microscopic chromosomal diagnosis or DNA
diagnosis is required to predict prognosis for the fetus;
(ii) A medical evaluation indicates the
possibility of a prenatally diagnosable fetal infection;
(iii) Fetal blood studies are medically
indicated for isoimmunization studies or therapy;
(iv) Fetal blood is the only means to provide
biochemical genetic diagnosis;
(v)
Prenatal diagnosis of a hematological disorder is medically
indicated.
(b) Prenatal
tissue biopsy if the nature of the disorder in question indicates that fetal
liver, skin, or other tissue biopsy is the only means to provide biochemical
genetic diagnosis to protect the health of the pregnant person or predict the
prognosis of the fetus.
(c)
Cytogenomic microarray analysis (CMA) if medically indicated because of an
abnormal ultrasound finding or known family history.
Statutory Authority:
RCW
48.21.244,
48.44.344,
48.46.375. 03-11-031, §
246-680-020, filed 5/15/03, effective 6/15/03. Statutory Authority:
RCW
43.20.050. 91-02-051 (Order 124B), recodified
as § 246-680-020, filed 12/27/90, effective 1/31/91. Statutory Authority:
RCW
48.21.244,
48.44.344 and
48.46.375. 90-02-094 (Order 024),
§ 248-106-020, filed 1/3/90, effective
2/3/90.
