Chromosomal microarray analysis may be considered medically necessary as first-line testing in the initial evaluation (see Policy Guidelines) of individuals with any of the following:
Apparent nonsyndromic developmental delay/intellectual disability,
Autism spectrum disorder, or
Multiple congenital anomalies not specific to a well-delineated genetic syndrome.
Chromosomal microarray is considered investigational for the evaluation of all other conditions of delayed development, including, but not limited to, idiopathic growth or language delay.
Panel testing using next-generation sequencing is considered investigational in all cases of suspected genetic abnormality in children with developmental delay/intellectual disability, autism spectrum disorder, or congenital anomalies.
