National Medical Policy

National Medical Policy Subject: Policy Number: Preimplantation Genetic Diagnosis in Assisted Reproduction NMP245 Effective Date*: October 2005 Updated: September 2015 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for coverage guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website Link National Coverage Determination (NCD) National Coverage Manual Citation Local Coverage Determination (LCD)* Article (Local)* Other X None Use Health Net Policy Instructions Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under Reference/Website and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. Preimplantation Genetic Diagnosis Sep 15 1

If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance. Current Policy Statement Many benefit plans specifically exclude in vitro fertilization (IVF) and related procedures. Health Net does not cover IVF services associated with preimplantation genetic diagnosis (PGD) unless the plan specifically covers IVF. Health Net, Inc. considers preimplantation genetic diagnosis (PGD) as an adjunct to in vitro fertilization (IVF) medically necessary to deselect embryos affected by flawed genetic make-up, when the results of the genetic test will impact clinical decision making and/or clinical outcome, and any of the following are met: 1. Women > 35 years of age to test for suspected aneuploidy - one or a few chromosomes above or below the normal chromosome number, e.g., three number 21 chromosomes or trisomy 21 (characteristic of Down syndrome) is a form of aneuploidy. 2. Couples at high risk for aneuploid pregnancy (e.g., prior aneuploid pregnancy) 3. Couples at high risk for single gene disorders* who meet any of the following: One partner has the diagnosis, is a known carrier or has a family history of a single gene, autosomal dominant chromosomal disorder Both partners are known carriers of a single gene autosomal recessive chromosomal disorder One partner is a known carrier of a single X-linked disorder 4. Couples who already have one child with a genetic problem and are at high risk of having another 5. There have been three or more prior failed attempts at IVF 6. Women with > 2 miscarriages (recurrent pregnancy losses) related to parental structural chromosome abnormality 7. Repeated implantation failure defined as the absence of a gestational sac on ultrasound at 5 weeks post-embryo transfer (e.g., > 3 embryo transfers with high quality embryos or the transfer of 10 embryos in multiple transfers) 8. To determine the sex of an embryo only when 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. 9. To evaluate human leukocyte antigen (HLA) status in families with a child with a malignant cancer or genetic disorder who is likely to be cured or whose life expectancy is expected to be substantially prolonged by a cord blood stem cell transplant after all other clinical options have been exhausted, and in whom there is no other source of a compatible bone marrow donor other than an HLA matched sibling. Preimplantation Genetic Diagnosis Sep 15 2

*Note: Single gene disorders include autosomal recessive diseases (e.g., cystic fibrosis, beta-thalassemia, Tay-Sachs), autosomal dominant diseases (e.g., Marfan's syndrome, myotonic dystrophy) and X-linked diseases (e.g., Duchenne and Becker's muscular dystrophy, hemophilia, fragile-x syndrome). Note: When the specific criteria noted above are met, we consider the polar body biopsy / cleavage stage embryo biopsy procedure to obtain the cell and the genetic test associated with PGD medically necessary. List of Genetically Determined Disorders Achondroplasia Alpha-1-antitrypsin deficiency Cystic fibrosis Fanconi anemia Hemophilia A and B Muscular dystrophy (Duchenne and Becker) osis type I Phenylketonuria Retinitis pigmentosa Spinal muscular atrophy Fragile X syndrome Rett syndrome Barth's syndrome Down's syndrome Adenosine deaminase deficiency Beta thalassemia Epidermolysis bullosa Gaucher disease Huntington disease Ornithine transcarbamylase (OTC) deficiency Myotonic dystrophy Retinoblastoma Sickle cell disease Tay Sachs disease Lesch-Nyhan syndrome Charcot-Marie-Tooth disease Turner syndrome Health Net, Inc. considers PGD not medically necessary for any of the following because there is a paucity of peer-reviewed studies: 1. The genetic code associated with the condition is not known to allow diagnosis with current genetic testing techniques 2. Genetic diagnosis is uncertain, e.g., due to genetic/molecular heterogeneity or uncertain mode of inheritance 3. PGD for the purposes of carrier testing to determine carrier status of the embryo (determination of carrier status is performed on individuals contemplating reproduction) 4. PGD for adult-onset/late-onset disorders (e.g., Alzheimer's disease; cancer predisposition) Health Net, Inc. considers PGD investigational for any of the following because although studies continue to be done, additional peer-reviewed studies are necessary to determine the safety, efficacy and long-term outcomes for these scenarios: Preimplantation Genetic Diagnosis Sep 15 3

1. PGD for the purpose of HLA typing of an embryo to identify a future suitable stem cell, tissue or organ transplantation donor; PGD has not been established as the standard of care for assessing the suitability of embryos for stem cell transplantation. 2. Testing of embryos for non-medical gender selection or non-medical traits. 3. The affected or sick child has an acute medical condition prohibiting safe stem cell transplantation or has extremely low life expectancy, such that there isn t enough time for the PGD test to be developed, applied and the birth of the HLAmatched sibling. Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. Health Net National Medical Policies will now include the preliminary ICD-10 codes in preparation for this transition. Please note that these may not be the final versions of the codes and that will not be accepted for billing or payment purposes until the October 1, 2015 implementation date. ICD-9 Codes 270.0-279.9 Other metabolic and immunity disorders 277.00-277.09 Cystic fibrosis 282.41-282.49 Thalassemias 282.60-282.69 Sickle-cell disease 284.0 Constitutional aplastic anemia 330.1 Cerebral lipidoses 359.0 Congenital hereditary muscular dystrophy 359.1 Hereditary progressive muscular dystrophy 653.70 Other fetal abnormality causing disproportion; unspecified as to episode of care or not applicable, delivered, with or without mention of antepartum condition, or antepartum condition or complication 655.00-655.90 Known or suspected fetal abnormality affecting management of mother; unspecified as to episode of care or not applicable, delivered, with or without mention of antepartum condition, or antepartum condition or complication 659.60, 1, 3 Elderly multigravida 741.00-742.9 Spina bifida and other congenital anomalies of nervous system 758.0-758.9 Chromosomal anomalies 759.82 Marfan syndrome 793.99 Other nonspecific abnormal findings on radiological and other examination of body structure V17.2 Family history of other neurological diseases V18.1 Family history of other endocrine and metabolic diseases V18.2 Family history of anemia Preimplantation Genetic Diagnosis Sep 15 4

V18.3 Family history of other blood disorders V18.4 Family history of mental retardation V19.5 Family history of congenital anomalies V19.8 Family history of other condition V23.81 Supervision of elderly primigravida V23.82 Supervision of elderly multigravida V23.89 Supervision of other high-risk pregnancy V28.0 Screening for chromosomal anomalies by amniocentesis V28.1 Screening for raised alpha-fetoprotein levels in amniotic fluid V28.2 Other screening based on amniocentesis V28.8 Other specified antenatal screening V82.4 Maternal postnatal screening for chromosomal anomalies V83.81 Cystic fibrosis gene carrier V83.89 Other genetic carrier status ICD-10 Codes D56.0- D56.9 Thalassemia D57.0- D57.819 Sickle-cell disorders D61.01- D61.09 Constitutional aplastic anemia E75.02 Tay-Sachs disease E75.19 Other gangliosidosis E75.4 Neuronal ceroid lipofuscinosis E75.02 Tay-Sachs disease E75.19 Other gangliosidosis E75.4 Neuronal ceroid lipofuscinosis E72.00- E72.9 Other disorders of amino-acid metabolism E84.0- E84.9 Cystic Fibrosis G71.0 Muscular dystrophy G71.2 Congenital myopathies O09.511- O89.529 Supervision of elderly primigravida and multigravida O09.811- O09.819 Supervision of other high risk pregnancies O33.7 Maternal care for disproportion due to other fetal deformities O35.0XX0- O35.0XX9 Maternal care for known or suspected fetal abnormality and Damage Q05.0- Q05.9 Spina Bifida Q06.0- Q06.9 Other congenital malformations of spinal cord Q87.40- Q87.89 Marfan s syndrome Q90.0- Q99 Chromosomal abnormalities, not elsewhere classified R93.8 Abnormal findings on diagnostic imaging of other specified body structures Z13.89 Encounter for screening for other disorder Preimplantation Genetic Diagnosis Sep 15 5

Z14.1 Cystic fibrosis carrier Z14.8 Genetic carrier of other disease Z36 Encounter for antenatal screening of mother Z81.0 Family history of intellectual disabilities Z82.0 Family history of epilepsy and other diseases of the nervous system Z83.2 Family history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Z83.41- Z83.49 Family history of other endocrine, nutritional, and metabolic diseases Z82.79 Family history of other congenital malformations, deformations and chromosomal abnormalities Z84.89 Family history of other specified conditions CPT Codes 81161 DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed 81200-81383 Tier 1 Molecular Pathology Procedures 81287 MGMT (0-6-methylguanine-DNA methyltransferase) (eg. Glioblastoma multiforme), methylation analysis 81376 HLA Class II typing, low resolution (eg. Antigen equivalents);one locus (eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or DPA1), each 81382 HLA Class II typing, high resolution (i.e., alleles or allele groups); one locus (eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or DPA1), each 81400-81479 Tier 2 Molecular Pathology Procedures 81400 Molecular pathogen procedure, Level 1 (eg, identification of single germline variant (eg. SNP) by techniques such as restriction enzyme digestion or melt curve analysis) 81401 Molecular pathogen procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder /triplet repeat) 81402 Molecular pathogen procedure, Level 3 (eg, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants [typically nonsequencing target variant analysis], immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants of 1 exon, loss of heterozygosity (LOH), uniparental disomy (UPD) (Revised in 2015) 81403 Molecular pathogen procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) (Revised in 2015) 81404 Molecular pathogen procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6-10 exons, or characterization of a Preimplantation Genetic Diagnosis Sep 15 6

dynamic mutation disorder/triplet repeat by Southern blot analysis) (Revised in 2015) 81405 Molecular pathogen procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons), regionally targeted cytogenomic array analysis (Revised in 2015) 81406 Molecular pathogen procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons, cytogenomic array analysis for neoplasia) 81407 Molecular pathogen procedure, Level 8 (eg, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform 81408 Molecular pathogen procedure, Level 9 (eg, analysis of >50 exons in a single gene by DNA sequence analysis 83890 Molecular diagnostics; molecular isolation or extraction, each nucleic acid type (i.e., DNA or RNA) (CPT Codes 83890-83914 deleted in 2014. To report see 81161, 81200-81479) 83898 Molecular diagnostics; amplification of patient nucleic acid (e.g. PCR, LCR), single primer pair, each primer pair (CPT Codes 83890-83914 deleted in 2014. To report see 81161, 81200-81479) 83901 Molecular diagnostics; amplification, target, multiplex, each additional nucleic acid sequence beyond 2 (List separately in addition to code for primary procedure) (CPT Codes 83890-83914 deleted in 2014. To report see 81161, 81200-81479) 88365 In situ hybridization, (FISH), per specimen; initial single probe stain procedure (Revised in 2015) 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); less than or equal to 5 embryos 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); greater than 5 embryos 2015 CPT Code 81288 MLH1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis HCPCS Codes S3625 S3835 S3837 S3840 S3841 S3842 S3843 Maternal serum triple marker screen including alpha-fetoprotein (AFP), estriol, and human chorionic gonadotropin (hcg) (Code deleted in 2014) Complete gene sequence analysis for cystic fibrosis genetic testing (Code deleted in 2013) Complete gene sequence analysis for hemochromatosis genetic testing (Code deleted in 2013) DNA analysis for germline mutations of the ret proto-oncogene for susceptibility to multiple endocrine neoplasia type 2 Genetic testing for retinoblastoma Genetic testing for von Hippel-Lindau disease DNA analysis of the F5 gene for susceptibility to Factor V Leiden thrombophilia (Code deleted in 2013) Preimplantation Genetic Diagnosis Sep 15 7

S3845 Genetic testing for alpha-thalassemia S3846 Genetic testing for hemoglobin E beta-thalassemia S3847 Genetic testing for Tay-Sachs disease (Code deleted in 2013) S3848 Genetic testing for Gaucher disease (Code deleted in 2013) S3849 Genetic testing for Niemann-Pick disease S3851 Genetic testing for Canavan disease (Code deleted in 2013) S3853 Genetic testing for myotonic muscular dystrophy S4011-S4022 In vitro fertilization Scientific Rationale Update September 2015 Girardet et al. (2015) completed a study that provides an overview of 10 years of experience of preimplantation genetic diagnosis (PGD) for cystic fibrosis (CF) in the author s center. Owing to the high allelic heterogeneity of CF transmembrane conductance regulator (CFTR) mutations a powerful universal test has been set up based on haplotyping eight short tandem repeats (STR) markers together with the major mutation p.phe508del. Of 142 couples requesting PGD for CF, 76 have been so far enrolled in the genetic work-up, and 53 had 114 PGD cycles performed. Twentynine cycles were canceled upon in vitro fertilization (IVF) treatment because of hyper- or hypostimulation. Of the remaining 85 cycles, a total of 493 embryos were biopsied and a genetic diagnosis was obtained in 463 (93.9%), of which 262 (without or with a single CF-causing mutation) were transferable. Twenty-eight clinical pregnancies were established, yielding a pregnancy rate per transfer of 30.8% in the group of seven couples with one member affected with CF, and 38.3% in the group of couples whose both members are carriers of a CF-causing mutation [including six couples with congenital bilateral absence of the vas deferens (CBAVD)]. So far, 25 children were born free of CF and no misdiagnosis was recorded. This test is applicable to 98% of couples at risk of transmitting CF. Scientific Rationale Update September 2012 Stem cell transplantation has significantly improved the prognosis for many life threatening diseases, (e.g., children affected with Fanconi's anemia). Identification of a disease-free embryo that is also HLA compatible to the affected child and can provide cord blood stem cells for transplantation will significantly improve the probability of survival of the affected sibling. PGD has been used successfully to identify HLA-compatible unaffected embryos to permit treatment of an affected sibling by cord blood transfusion or bone marrow transplantation. However, very few of the embryos tested (about 16 percent) will be both unaffected and an HLA match for the affected sibling. In addition, finding an HLA-matched donor is not always possible, especially for minorities. While autologous hematopoietic stem cells provide perfectly compatible tissue, this type of transplantation is not appropriate in many cases, due to the presence of the disease to be treated in the collected autologous stem cells. Each full sibling potential donor has only a 25 percent chance of being fully HLA-matched with a sibling who requires a transplant. Therefore, many patients do not have an HLAidentical relative. When a suitable related donor is not available, a search is conducted to identify a potential unrelated HLA-matched donor. Finding an appropriate donor through a national registry is a lengthy process that is not always successful, especially for individuals who are not of Northern European descent. As a result, many patients who might benefit from HCT are not afforded this opportunity, or die during the extended process of securing a donor. Preimplantation Genetic Diagnosis Sep 15 8

Harper et al. (2012) For the last 20 years, preimplantation genetic diagnosis (PGD) has been mostly performed on cleavage stage embryos after the biopsy of 1-2 cells and PCR and FISH have been used for the diagnosis. The main indications have been single gene disorders and inherited chromosome abnormalities. Preimplantation genetic screening (PGS) for aneuploidy is a technique that has used PGD technology to examine chromosomes in embryos from couples undergoing IVF with the aim of helping select the chromosomally 'best' embryo for transfer. It has been applied to patients of advanced maternal age, repeated implantation failure, repeated miscarriages and severe male factor infertility. Recent randomized controlled trials (RCTs) have shown that PGS performed on cleavage stage embryos for a variety of indications does not improve delivery rates. At the cleavage stage, the cells biopsied from the embryo are often not representative of the rest of the embryo due to chromosomal mosaicism. There has therefore been a move towards blastocyst and polar body biopsy, depending on the indication and regulations in specific countries (in some countries, biopsy of embryos is not allowed). Blastocyst biopsy has an added advantage as vitrification of blastocysts, even post biopsy, has been shown to be a very successful method of cryopreserving embryos. However, mosaicism is also observed in blastocysts. There have been dramatic changes in the method of diagnosing small numbers of cells for PGD. Both array-comparative genomic hybridisation and single nucleotide polymorphism arrays have been introduced clinically for PGD and PGS. For PGD, the use of SNP arrays brings with it ethical concerns as a large amount of genetic information will be available from each embryo. For PGS, RCTs need to be conducted using both array-cgh and SNP arrays to determine if either will result in an increase in delivery rates. Scientific Rationale Update October 2011 Colls et al. (2009) Preimplantation genetic diagnosis (PGD) for gender selection for non-medical reasons has been considered an unethical procedure by several authors and agencies in the Western society on the basis that it could disrupt the sex ratio, that it discriminates against women and that it leads to disposal of normal embryos of the non-desired gender. In this study, the analysis of a large series of PGD procedures for gender selection from a wide geographical area in the USA shows that, in general, there is no deviation in preference towards any specific gender except for a preference of males in some ethnic populations of Chinese, Indian and Middle Eastern origin that represent a small percentage of the US population. In cases where only normal embryos of the non-desired gender are available, 45.5% of the couples elect to cancel the transfer, while 54.5% of them are open to have embryos transferred of the non-desired gender, this fact being strongly linked to cultural and ethnic background of the parents. In addition this study adds some evidence to the proposition that, in couples with previous children of a given gender, there is no biological predisposition towards producing embryos of that same gender. El-Toukhy et al. (2010) completed a review to inform the clinician about the application, success rates and limitations of preimplantation genetic diagnosis (PGD) for hematologic disease to enable clinicians to offer couples with reproductive risk a realistic view of possible treatments. The history and ethics involved in performing PGD together with human leukocyte antigen (HLA) testing (PGD-H) to create matched siblings suitable for hematopoietic stem cell transplant (HSCT) are discussed. The greatest diagnostic hurdle in PGD is the paucity of molecular material in the single embryonic cell. PGD to exclude embryos carrying serious hematologic disease is a viable alternative to prenatal diagnosis for couples whom wish to avoid having affected children and for whom therapeutic termination of affected pregnancies is unacceptable. PGD is not available for all hematologic mutations, is Preimplantation Genetic Diagnosis Sep 15 9

expensive, time consuming and does not guarantee a pregnancy. PGD-H is more diagnostically and ethically challenging, especially when there is the time constraint of urgent provision of HLA-matched stem cells for a sick sibling. To date there is only a handful of reported cases of successful HSCT from siblings created by embryo selection. Pre-implantation genetic diagnosis (PGD) has been proposed as a method for selecting HLA-matched embryos in order to create a tissue matched child that can serve as a stem cell donor. After delivery of the HLA-matched baby, umbilical cord blood (UCB) cells can be collected and cryopreserved for transplantation to the sick sibling or the affected child. Using pre-implantation HLA typing to have a tissuematched child that can serve as a haematopoietic stem cell donor to save a loved one s life. This is generally known as the creation of saviour siblings. Haematopoietic stem cells are found in the umbilical cord blood, bone marrow and peripheral blood. Despite recent promising results of using stem cells from the umbilical cord blood of so called saviour siblings for curing patients with blood diseases and certain types of cancer, this method has been met with much opposition. Concerns related to the risks of preimplantation genetic diagnosis (PGD) for the child to be born, the intention to have a donor child, the limits that should be placed on what cells or organs can be used from the child and whether the recipient can be someone other than a sibling). Preimplantation tissue typing has been proposed as a method for creating a tissue matched child that can serve as a haematopoietic stem cell donor to save its sick sibling in need of a stem cell transplant. Despite recent promising results, many people have expressed their disapproval of this method. Scientific Rationale Update February 2011 Tay Sachs Disease Altaruscu et al. (2007) Preimplantation genetic diagnosis (PGD) for single gene defects is described for a family in which each parent is a carrier of both Tay-Sachs (TS) and Gaucher disease (GD). A multiplex fluorescent polymerase chain reaction protocol was developed that simultaneously amplified all four familial mutations and 10 informative microsatellite markers. In one PGD cycle, seven blastomeres were analysed, reaching a conclusive diagnosis in six out of seven embryos for TS and in five out of seven embryos for GD. Of the six diagnosed embryos, one was wild type for both TS and GD, and three were wild type for GD and carriers of TS. Two remaining embryos were compound heterozygotes for TS. Two transferable embryos developed into blastocysts (wt/wt and wt GD/carrier TS) and both were transferred on day 5. This single cycle of PGD resulted in a healthy live child. Allele drop-out (ADO) was observed in three of 34 reactions, yielding an 8% ADO rate. The occurrence of ADO in single cell analysis and undetected recombination events are primary causes of misdiagnosis in PGD and emphasize the need to use multiple polymorphic markers. So far as is known, this is the first report of concomitant PGD for two frequent Ashkenazi Jewish recessive disorders. Fragile X Syndrome Malcov et al. (2007) Fragile X syndrome is caused by a dynamic mutation in the FMR1 gene. Normal individuals have <55 CGG repeats in the 5 untranslated region, premutation carriers have 55-200 repeats and a full mutation has >200 repeats. Female carriers are at risk of having affected offspring. A multiplex nested polymerase chain reaction protocol is described for preimplantation genetic diagnosis (PGD) of fragile X syndrome with simultaneous amplification of the CGG-repeat region, the Sry gene and several flanking polymorphic markers. The amplification Preimplantation Genetic Diagnosis Sep 15 10

efficiency was > or =96% for all loci. The allele dropout rate in heterozygotic females was 9% for the FMR1 CGG-repeat region and 5-10% for the polymorphic markers. Amplification failure for Sry occurred in 5% of single leukocytes isolated from males. PGD was performed in six patients who underwent 15 cycles. Results were confirmed in all cases by amniocentesis or chorionic villous sampling. Five clinical pregnancies were obtained (31% per cycle), four of which resulted in a normal delivery and one miscarried. This technique is associated with high efficiency and accuracy and may be used in carriers of full mutations and unstable high-order premutations. Giardet et al. (2008) Two multiplex PGD protocols were developed allowing the detection of the common homozygous deletion of the telomeric spinal muscular atrophy gene (SMN1), together with two microsatellites located on each side of SMN1. The molecular genetics laboratory of the university hospital in Montpellier. PATIENT(S): A couple who had already given birth to a child affected with SMA.) In vitro fertilization using intracytoplasmic sperm injection (ICSI) and blastomere biopsy. MAIN OUTCOME MEASURE(S): Improvement of PGD for SMA. Two different multiplex protocols were set up on 81 (multiplex A) and 64 single cells (multiplex B) from normal controls, affected patients, and individuals with homozygous SMN2 deletion. In one PGD cycle that used one of these protocols, two embryos were transferred, which resulted in the birth of a healthy baby. Analysis of microsatellite markers in addition to the SMN1 deletion allows the detection of contamination, the study of ploidy of the biopsied blastomeres, and the performance of an indirect genetic diagnosis, thereby increasing the reliability of the results. This PGD assay may be applied to all families with the common deletion of SMN1 and also to couples in whom one of the partners carries a small intragenic mutation in SMN1, identified in about 6% of affected individuals who do not lack both copies of SMN1. Shaw et al. (2008) Thirty-three members of 7 families participated in carrier test and disease detection of SMA. Prenatal genetic diagnosis was performed if both parents were carriers or any family members had SMA. DNA extracted from blood, chorionic villi and amniotic fluid was amplified and used for DHPLC. Twenty SMA carriers, seven SMA affected cases, and six normal individuals were identified. SMA status was demonstrated by genotyping and total copy number determinations of SMN1 and SMN2. Families 1-3 were classified as group one (SMA affecting previously born child). Group two, comprising families 4 and 5, had lost a child due to an unknown muscular disease. Group three (SMA-affected parent) comprised families 6 and 7; carrier testing was done. DHPLC prenatal genetic diagnosis was made in seven pregnancies, one in each family (affected, n=2; carrier, n=3; normal, n=2). Pregnancy was terminated for the two affected fetuses. The others were delivered uneventfully and SMA free. DHPLC prenatal diagnosis of SMA and determination of SMA status in adults is possible, and SMN1 and SMN2 copy numbers can be determined. Alpha-1-antitrypsin deficiency Alpha-1 antitrypsin (AAT) deficiency emphysema is an inherited disorder affecting approximately 100,000 Americans. Affected patients have little or no blood and tissue levels of AAT (also called alpha-1 protease inhibitor, alpha1-pi, or A1-PI), which protects the lung from destruction by enzymes in the lung that normally digest bacteria and other invaders. Unchecked, this enzyme progressively damages healthy lung tissue leading to decreased lung function and emphysema. The prognosis for patients with high-risk phenotypes for AAT deficiency emphysema is poor although symptomatic treatments and more definitive lung surgery are options. Preimplantation Genetic Diagnosis Sep 15 11

Cystic Fibrosis Norton et al. (2008) Recent advances in genetic technology have substantial implications for prenatal screening and diagnostic testing. The past year has also seen important changes in recommendations surrounding the genetic counseling that occurs in the provision of such testing. Multiple screening tests for single gene disorders, chromosomal abnormalities, and structural birth defects are now routinely offered to all pregnant women. Ethnicity-based screening for single gene disorders includes Tay Sachs disease, cystic fibrosis, and hemoglobinopathies. Recent discussions have involved, not only additional disorders that warrant screening, but a re-evaluation of the paradigm of selecting disorders for population-based screening. Testing for chromosomal abnormalities has seen the introduction of first-trimester screening, as well as strategies to improve detection through sequential testing. Changes in recommendations for screening compared with diagnostic testing, and a move away from maternal age-based dichotomizing of testing, have had major implications for provision of genetic counseling by providers of prenatal care. Advances in genetic testing have resulted in tremendous benefits to patients, and challenges to providers. New approaches to education and counseling are needed to assure that all patients receive a complete and balanced review of their prenatal genetic-testing options. Fanconi Anemia Modern Ashkenazi Jewish (AJ) populations (Ashkenazic Jews or Ashkenazim) descended from the Jewish communities of Germany, Poland, Austria, and Eastern Europe. Approximately 90% of the 5.7 million individuals of Jewish descent in the USA today are of AJ origin. Certain childhood-onset autosomal recessive genetic disorders are more common among the AJ community including Tay-Sachs disease, Canavan disease, familial dysautonomia, Bloom syndrome, Fanconi anemia group C, Gaucher disease, mucolipidosis type IV, Niemann-Pick disease type 1A, cystic fibrosis, and primary dystonia type 1 (torsion dystonia). Over the last few decades, the molecular basis of these diseases has been elucidated providing the tools and the opportunity to perform preconceptual carrier screening for these disorders in this ethnic group. The relatively homogeneous genetic make-up of the AJ population has resulted in there being a relatively limited number of disease-causing sequence variants accounting for the majority of cases of each disease which has allowed for the development of screening panels with a high level of sensitivity and specificity for the AJ population. As a result of the autosomal recessive mode of inheritance for these disorders, if both members of a couple are carriers, they have a 25% chance of having a child with the disorder. Fifteen autosomal recessive disorders were reviewed in order to determine whether or not they should be included in an AJ screening panel. The 15 disorders are: alpha-1-antitrypsin deficiency (AAD), Bloom syndrome (BLM), Canavan disease (CD), CF, deafness neurosensory autosomal recessive 1 (DFNB1), FD, familial hyperinsulinism (FHI), Fanconi anemia type C (FAC), Gaucher disease type 1 (GD), glycogen storage disease type 1A (GSD), maple syrup urine disease type 1b (MSUD), mucolipidosis type IV (MLIV), Niemann-Pick disease types A and B (NPDA&B), nonclassical congenital adrenal hyperplasia (NCAH), and Tay-Sachs disease (TSD). There is controversy, however, surrounding which diseases should be included in such screening panels. While serious, generally fatal disorders such as Tay-Sachs disease and Canavan disease are clear candidates for screening; the argument is not as clear for disorders with variable clinical presentation and reduced penetrance such as Gaucher disease or primary dystonia. Fares et al. (2008) completed a study, with a database containing the results of 410 genotyping assays was screened. Ten thousand seventy eight nonselected healthy Preimplantation Genetic Diagnosis Sep 15 12

members of the AJ population were tested for carrier status for the following diseases; Gaucher disease (GD), cystic fibrosis (CF), Familial dysautonomia (FD), Alpha 1 antitrypsin (A1AT), Mucolipidosis type 4 (ML4), Fanconi anemia type C (FAC), Canavan disease (CD), Neimann-Pick type 4 (NP) and Bloom syndrome (BLM). The results demonstrated that 635 members were carriers of one mutation and 30 members were found to be carriers of two mutations in the different genes related to the development of the above mentioned diseases. GD was found to have the highest carrier frequency (1:17) followed by CF (1:23), FD (1:29), A1AT (1:65), ML4 (1:67) and FAC (1:77). The carrier frequency of CD, NP and BLM was 1:82, 1:103 and 1:157, respectively. The frequency of the disease-causing mutations screened routinely among the AJ population indicated that there are rare mutations with very low frequencies. The screening policy of the disease-causing mutations should be reevaluated and mutations with a high frequency should be screened, while rare mutations with a lower frequency may be tested in partners of carriers. Hemophilia A for Hemophilia A/Factor 8 Deficiency Laurie et al. (2010) Preimplantation genetic diagnosis (PGD) is an option for couples at risk of having a child with hemophilia A (HA). Although many clinics offer PGD for HA by gender selection, an approach that detects the presence of the underlying F8 mutation has several advantages. The objection was to develop and validate analysis protocols combining indirect and direct methods for identifying F8 mutations in single cells, and to apply these protocols clinically for PGD. A panel of microsatellite markers in linkage disequilibrium with F8 were validated for single-cell multiplex polymerase chain reaction. For point mutations, a primer extension genotyping assay was included in the multiplex. Amplification efficiency was evaluated using buccal cells and blastomeres. Four clinical PGD analyses were performed, for two families. Results: Across all validation experiments and the clinical PGD cases, approximately 80% of cells were successfully genotyped. Following one of the PGD cycles, healthy twins were born to a woman who carries the F8 intron 22 inversion. The PGD analysis for the other family was complicated by possible germline mosaicism associated with a de novo F8 mutation, and no pregnancy was achieved. Conclusions: PGD for the F8 intron 22 inversion using microsatellite linkage analysis was validated by the birth of healthy twins to one of the couples. The other family's situation highlighted the complexities associated with de novo mutations, and possible germline mosaicism. As many cases of HA result from de novo mutations, these factors must be considered when assessing the reproductive options for such families. Per the American Congress of Obstetricians and Gynecologists (ACOG). ACOG Committee Opinion. Number 430 March 2009. Preimplantation Genetic Screening for Aneuploidy states the following: Preimplantation genetic screening differs from preimplantation genetic diagnosis for single gene disorders and was introduced for the detection of chromosomal aneuploidy. Current data does not support a recommendation for preimplantation genetic screening for aneuploidy using fluorescence in situ hybridization solely because of maternal age. Also, preimplantation genetic screening for aneuploidy does not improve in vitro fertilization success rates and may be detrimental. At this time there are no data to support preimplantation genetic screening for recurrent unexplained miscarriage and recurrent implantation failures; its use for these indications should be restricted to research studies with appropriate informed consent. Preimplantation genetic screening differs from preimplantation genetic diagnosis (PGD) for single gene disorders. In order to perform genetic testing for Preimplantation Genetic Diagnosis Sep 15 13

single gene disorders, PGD was introduced in 1990 as a component of in vitro fertilization programs. Such testing allows the identification and transfer of embryos unaffected by the disorder in question and may avoid the need for pregnancy termination. Assessment of polar bodies as well as single blastomeres from cleavage stage embryos has been reported, although the latter is the approach most widely practiced. Preimplantation genetic diagnosis has become a standard method of testing for single gene disorders, and there have been no reports to suggest adverse postnatal effects of the technology. Preimplantation genetic diagnosis has been used for diagnosis of translocations and single-gene disorders, such as cystic fibrosis, X- linked recessive conditions, and inherited mutations, which increase one s risk of developing cancer. In contrast, in the latter half of the 1990s, preimplantation genetic screening was introduced for the detection of chromosomal aneuploidy (2 4). Aneuploidy leads to increased pregnancy loss with increasing maternal age and also was thought to be a major cause of recurrent pregnancy loss in patients using assisted reproductive technologies. However, when compared with the molecular diagnostics available for PGD of single gene disorders, the current technologies available for preimplantation genetic screening for aneuploidy are more limited. Preimplantation genetic screening using fluorescence in situ hybridization is constrained by the technical limitations of assessing the numerical status of each chromosome. Typically assessed are the chromosome abnormalities associated with common aneuploidies found in spontaneous abortion material, and because of this, and other limitations noted in this Committee Opinion, a significant false-negative rate exists. Therefore, this form of testing should be considered a screening test, and not a diagnostic test, as is the case for PGD for single gene disorders. Because preimplantation chromosome assessment tests a single cell, there are certain limitations: Testing a single cell prohibits confirmation of results. There is a limit to the number of tests that can be done with a single cell. Embryo mosaicism of normal and aneuploid cell lines may not be clinically significant. Guidelines for counseling on limitations of this screening have been developed by the American Society for Reproductive Medicine. Recommendations of ACOG: Current data does not support a recommendation for preimplantation genetic screening for aneuploidy using fluorescence in situ hybridization solely because of maternal age. Preimplantation genetic screening for aneuploidy does not improve in vitro fertilization success rates and may be detrimental. At this time there are no data to support preimplantation genetic screening for recurrent unexplained miscarriage and recurrent implantation failures; its use for these indications should be restricted to research studies with appropriate informed consent. Scientific Rationale Initial With recent advances in genetics, there are a good number of inherited disorders, which can now be diagnosed at a molecular level. For couples who are carriers or affected by any of a variety of genetic diseases and are at high risk for transmitting Preimplantation Genetic Diagnosis Sep 15 14

it to their offspring, it is currently possible to detect the disorder during pregnancy. This is done by one of two approaches: chorionic villus sampling in the first trimester or amniocentesis in the second trimester. However the couples have the dilemma of whether or not to terminate the pregnancy if the genetic abnormality is present. In some cases this may also not be a viable option for religious or moral reasons. An alternative would then be to diagnose the condition in embryos before the pregnancy is established. Only the unaffected embryos would then be transferred to the uterus. This new technique that combines advances in molecular genetics and assisted reproductive technologies is referred to as preimplantation genetic diagnosis (PGD). It does not involve the manipulation of genes in embryos; rather, it selects among embryos. PGD involves several steps: the creation of an embryo via IVF; the removal of one or two cells from the embryo; the genetic testing of these cells for specific genetic conditions; and the subsequent transfer of unaffected embryos to a woman s uterus. Currently, IVF is the only available technique for obtaining an embryo in the very early stages of development. One to two single cells, blastomeres, are removed from early cleavage stage embryos (6 8-cell stage) at approximately 3 days' postfertilization. The blastomere contains genetic material that can be analyzed to identify three categories of disorders, including aneuploidy and structural chromosomal abnormalities, single-gene disorders, and X-linked disorders. Although couples with a high risk of transmitting a genetic defect to their offspring may have normal fertility, they would need to go through the IVF procedure to provide embryos for screening. Fertility specialists can use the results of this analysis to select only mutation-free embryos for implantation into the mother's uterus, hence preventing the physical and psychological trauma associated with possible termination. Clinical and practical considerations include that the embryo must be healthy enough to survive the procedure. It is estimated that only 2.5% of eggs collected will form a viable unaffected pregnancy. Maternal age is an important factor, particularly for aneuploidy screening in women older than 35 years of age, as this increases the likelihood of finding a chromosomal abnormality and decreases the success rate of IVF. With PGD, couples are much more likely to have healthy babies. Although PGD has been practiced for years, only a few specialized centers worldwide offer this procedure. PGD should be offered for 3 major groups of disease, including (1) sex-linked disorders, (2) single gene defects, and (3) chromosomal disorders. X-linked diseases are passed to the child through a mother who is a carrier. They are passed by an abnormal X chromosome and manifest in sons, who do not inherit the normal X chromosome from the father. Affected fathers have sons who are not affected, and their daughters have a 50% risk of being carriers if the mother is healthy. Sex-linked recessive disorders include hemophilia, fragile X syndrome, most of the neuromuscular dystrophies (currently > 900 neuromuscular dystrophies are known), and hundreds of other diseases. Sex-linked dominant disorders include Rett syndrome, incontinentia pigmenti, pseudohyperparathyroidism, and vitamin D resistant rickets. This genetic test is currently available to couples whose offspring are at a high risk (25-50%) for a specific genetic condition due to one or both parents being carriers or affected by the disease. Also the genetic code associated with the condition must be known in order to allow diagnosis. Currently, it is not feasible to routinely screen women at lower risks, such as women over age 35 for Downs Syndrome, since the means of establishing a pregnancy is with the help of IVF. Preimplantation Genetic Diagnosis Sep 15 15

PGD is used to identify single gene defects such as cystic fibrosis, Tay-Sachs disease, sickle cell anemia, and Huntington disease. In such diseases, the molecular abnormality is detectable with molecular techniques using PCR amplification of DNA from a single cell. Although progress has been made, some single gene defects have a wide variety of rare mutations (e.g., cystic fibrosis has approximately 1000 known mutations). Only 25 of these mutations are currently routinely tested. Because most of these rare mutations are not routinely tested, a parent without any clinical manifestations of cystic fibrosis could be a carrier. This allows the possibility for a parent carrying a rare mutation gene to be tested as negative but still have the ability to pass on the mutant cystic fibrosis gene. The last group includes chromosomal disorders in which a variety of chromosomal rearrangements, including translocations, inversions, and deletions, can be detected using FISH. Some parents may have never achieved a viable pregnancy without using PGD because previous conceptions resulted in chromosomally unbalanced embryos and were spontaneously miscarried. The risk of aneuploidy in children increases as women age. The chromosomes in the egg are less likely to divide properly, leading to an extra or missing chromosome in the embryo. The rate of aneuploidy in embryos is greater than 20% in mothers aged 35-39 years and is nearly 40% in mothers aged 40 years or older. The rate of aneuploidy in children is 0.6-1.4% in mothers aged 35-39 years and is 1.6-10% in mothers older than 40 years. The difference in percentages between affected embryos and live births is due to the fact that an embryo with aneuploidy is less likely to be carried to term and will most likely be miscarried, some even before pregnancy is suspected or confirmed. Therefore, using PGD to determine the chromosomal makeup of embryos increases the chance of a healthy pregnancy and reduces the number of pregnancy losses and affected offspring with so-called serious inherited disorders such as Tay Sachs; Trisomies 13, 18, and 21; cystic fibrosis; muscular dystrophy; Huntington disease; Lesch-Nyhan; and neurofibromatosis. PDG is also presently has much wider indications than prenatal diagnosis, including common diseases with genetic predisposition and preimplantation human leukocyte antigen typing, with the purpose of establishing potential donor progeny for stem cell treatment of siblings. Many hundreds of apparently healthy, unaffected children have been born after preimplantation genetic diagnosis, presenting evidence of its accuracy, reliability and safety. Preimplantation genetic diagnosis appears to be of special value for avoiding age-related aneuploidies in patients of advanced reproductive age, improving reproductive outcome, particularly obvious from their reproductive history, and is presently an extremely attractive option for carriers of balanced translocations to have unaffected children of their own. Many people fear that PGD will be used to select a child of a preferred sex. PGD could also be used in attempts to select a future child's cosmetic, behavioral, and other non-disease traits. However, the genetic laws of independent assortment make it difficult for PGD to be used for any traits that depend on two or more genes. Thus, PGD provides an alternative to germline modification as a way to prevent the births of children with serious genetic diseases, most of which are single-gene disorders, but does not open the door to escalating and species-altering applications. Research continues in the area of PGD. There is now a rapidly growing list of disorders for which PGD has been applied successfully, including cystic fibrosis, Tay- Sachs disease, hemophilia A and B, retinitis pigmentosa, numerous inborn errors of metabolism, fragile X syndrome, Duchenne muscular dystrophy, and chromosomal abnormalities, to name a few. The risks of PGD are similar to risks for IVF, namely Preimplantation Genetic Diagnosis Sep 15 16

multiple-fetal pregnancies and the twofold increased risk for major birth defects and low birth weight. Preliminary studies show no increased risk for spontaneous abortions. The data from long-term follow-up of children conceived after PGD, however, have yet to be collected. Review History October 2005 November 2006 November 2007 February 2011 October 2011 September 2012 September 2013 September 2014 September 2015 Medical Advisory Council initial approval Medical Advisory Council - no changes Update no revisions Update. Added Medicare Table. No revisions. Update - no revisions Update no revisions Update no revisions. Code updates Update no revisions. Code updates. Update no revisions. Code updates. This policy is based on the following evidence-based guidelines: 1. American College of Obstetricians and Gynecologists, American College of Medical Genetics: Preconception and Prenatal Carrier Screening for Cystic Fibrosis: Clinical and Laboratory Guidelines. Washington, DC; American College of Obstetrics and Gynecology; October, 2001. 2. American Society for Reproductive Medicine, Society for Assisted Reproductive Technology: A practice committee report: Preimplantation genetic diagnosis. Birmingham, Ala. June 2001. 3. National Ethics Committee on Assisted Human Reproduction. Guidelines for Preimplantation Genetic Diagnosis in New Zealand. Consultation Document. September 2004. 4. Thornhill AR, dedie-smulders CE, Geraedts JP, et al. European Society of Human Reproduction and Embryology (ESHRE) PGD Consortium. Best practice guidelines for clinical preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS). 2005. Available at: http://humrep.oxfordjournals.org/cgi/content/full/20/1/35#sec4 5. Developments in infertility therapy. Diagnosis of genetic disease in embryos. Australian Family Physician Vol. 34, No. 3, March 2005. 6. International Working Group on Preimplantation Genetics, International Congress of Human Genetics: Preimplantation Genetic Diagnosis: Experience of Three Thousand Cycles. Report of the 11th Annual Meeting of International Working Group on Preimplantation Genetics, in association with 10th International Congress of Human Genetics. Vienna, Austria; May, 2001. 7. American Society For Reproductive Medicine. Preimplantation Genetic Diagnosis Fact Sheet. 12/96. 8. Preimplantation genetic testing: a Practice Committee opinion. Practice Committee of the Society for Assisted Reproductive Technology; Practice Committee of the American Society for Reproductive Medicine. Fertil Steril 2007;88:1497 504. 9. Hayes. Medical Technology Directory. Genetic Testing for Tay-Sachs Disease. Updated March 6, 2008. Archived November 12, 2008. 10. Hayes. Genetic Test Overview. Fragile X Syndrome (FMR1) for Mental Retardation. August 7, 2008, Updated August 1, 2012. Archived July 13, 2013. 11. Hayes. Genetic Test Overview. Y Chromosome Microdeletion Analysis for Male Infertility. November 14, 2008, Updated December 6, 2011. Archived December 14, 2013 Preimplantation Genetic Diagnosis Sep 15 17

12. American Congress of Obstetricians and Gynecologists (ACOG). ACOG Committee Opinion. Number 430. March 2009. Preimplantation Genetic Screening for Aneuploidy. Reaffirmed 2014. 13. Hayes. Genetic Test Overview. Spinal Muscular Atrophy (SMA) for Progressive Muscle Weakness. January 23, 2009, Updated January 31, 2012. Updated January 17, 2013. Archived February 23, 2014. 14. Hayes. Genetic Test Evaluation Overview. Ashkenazi Jewish Genetic Screening Panel for Risk Assessment. February 18, 2009, Updated February 15, 2012. Updated February 13, 2013. Archived March 18, 2014. 15. Hayes. Genetic Test Overview. COL1A1 and COL1A2 Testing for Osteogenesis Imperfecta Types I to IV. February 20, 2009, Updated February 14, 2012. Archived March 20, 2014. 16. Hayes. Genetic Test Overview. GTE Report: Charcot-Marie-Tooth Type 1A (PMP22). Published: August 5, 2008. Updated Aug 23, 2010, Updated July 31, 2012. Archived June 30, 2013. 17. Hayes. Genetic Test Overview. Spinocerebellar Ataxia Type 1 (SCA1) for Movement Disorders. March 3, 2010, Updated February 10, 2012. Archived March 9, 2014. 18. Hayes. Genetic Test Overview. GTE Report: Myotonic Dystrophy Types 1 and 2 Published: March 9, 2009. Latest Update Search: Mar 31, 2010, Updated March 2, 2012. Archived April 9, 2014. 19. Hayes. Genetic Test Overview. Spinocerebellar Ataxia Type 2 (SCA2) for Movement Disorders. March 3, 2010, Updated February 10, 2012. Archived March 23, 2014 20. Hayes. Genetic Test Overview. Spinocerebellar Ataxia Type 3 (SCA3; Machado- Joseph Disease) for Movement Disorders. March 3, 2010, Updated February 13, 2012. Archived February 27, 2014. 21. Hayes. Genetic Test Overview. Spinocerebellar Ataxia Type 6 (SCA6) for Movement Disorders. March 31, 2010, Updated March 13, 2012. Archived April 11, 2014. 22. Hayes. Genetic Test Overview. Spinocerebellar Ataxia Type 7 (SCA7) Movement Disorder. April 29, 2010, Updated April 18, 2012. Archived May 29, 2014. 23. Hayes. Genetic Test Overview. GTE Report: Huntington Chorea/Disease (HD) for Diagnostic, Predictive, and Prenatal or Preimplantation Genetic Diagnosis Purposes. Published: April 29, 2008. Updated May 6, 2010, Updated April 25, 2012. Archived May 29, 2013. 24. Hayes. Genetic Test Overview. Comparative Genomic Hybridization (CGH) Microarray for Chromosomal Imbalance. April 12, 2010, Updated February 7, 2012. Updated May 22, 2013. Updated May 19, 2014. 25. Hayes. Genetic Test Overview. Marfan Syndrome. May 7, 2010, Updated April 27, 2012. Archived May 2, 2014. 26. Hayes. Genetic Test Overview. Spinocerebellar Ataxia Type 12 (SCA12) for Movement Disorders. June 15, 2010, Updated June 2, 2011. Archived 2014. 27. Hayes. Genetic Test Overview. Spinocerebellar Ataxia Type 17 (SCA17) for Movement Disorders. June 17, 2010, Updated May 22, 2012. Archived July 25, 2014 28. Hayes. Genetic Test Overview. GTE Report: Neurofibromatosis Type 1 (NF1). Published: November 17, 2010, Updated April 5, 2012. Updated April 2, 2014. 29. Hayes. Genetic Test Overview. GTE Synopsis: Hemophilia A (Factor VIII Deficiency). Published: January 24, 2011, Updated June 19, 2012. Updated July 11, 2013. Updated June 8, 2015. Preimplantation Genetic Diagnosis Sep 15 18

30. American College of Obstetricians and Gynecologists (ACOG). Committee Opinion. Family History as a Risk Assessment Tool. Number 478. March 2011. Reaffirmed 2015. 31. Hayes. GTE. Cystic Fibrosis Transmembrane Regulator (CFTR) for Cystic Fibrosis. May 30, 2013. Updated May 20, 2014. Updated May 13, 2015. 32. Hayes. Medical Technology Directory. Genetic Carrier Testing for Cystic Fibrosis. June 7, 2004. Updated August 1, 2008. Archived July 7, 2009. 33. Hayes. GTE Overview. Tay-Sachs Disease (TSD) Testing in Individuals of Non- Jewish Origin. December 8, 2011. Updated December 11, 2013. Updated December 4, 2014. 34. Hayes. GTE Synopsis. X-Linked Intellectual Disability (XLID) Multigene Panels. November 6, 2013. Updated December 4, 2014. 35. Hayes. GTE. FMR1 Testing for Fragile X-Associated Tremor/Ataxia Syndrome. May 20, 2013. Archived July 16, 2014. References Update September 2015 1. Baker MW, Atkins AE, Cordavado SK, et al. Improving newborn screening for cystic fibrosis using next-generation sequencing technology: a technical feasibility study. Genet Med. 2015 Feb 12. doi: 10.1038/gim.2014.209. [Epub ahead of print] 2. Girardet A, Ishmukhametova A, Willems M, et al. Preimplantation genetic diagnosis for cystic fibrosis: the Montpellier center's 10-year experience. Clin Genet. 2015 Feb;87(2):124-32. doi: 10.1111/cge.12411. Epub 2014 May 20. 3. Lim RM, Silver AJ, Silver MJ, et al. Targeted mutation screening panels expose systematic population bias in detection of cystic fibrosis risk. Genet Med. 2015 Apr 16. doi: 10.1038/gim.2015.52. [Epub ahead of print] 4. Loukas YL, Thodi G, Molou E, et al. Clinical diagnostic Next-Generation sequencing: The case of CFTR carrier screening. Scand J Clin Lab Invest. 2015 Apr 15:1-8. [Epub ahead of print] 5. Redin C, Gérard B, Lauer J, et al. Efficient strategy for the molecular diagnosis of intellectual disability using targeted high-throughput sequencing. J. Med. Genet. 2014;51(11):724 736. 6. Salinas DB, Sosnay PR, Azen C, et al. Benign outcome among positive cystic fibrosis newborn screen children with non-cf-causing variants. J Cyst Fibros. 2015 Mar 28. pii: S1569-1993(15)00061-2. doi: 10.1016/j.jcf.2015.03.006. [Epub ahead of print]. References Update September 2014 1. Girardet A, Ishmukhametova A, Willems M, et al. Preimplantation Genetic Diagnosis for Cystic Fibrosis: the Montpellier centre's 10-year experience. Clin Genet. 2014 Apr 25. doi: 10.1111/cge.12411. [Epub ahead of print]. 2. Olson H, Shen Y, Avallone J, et al. Copy number variation plays an important role in clinical epilepsy. Ann Neurol. 2014 May 9. doi: 10.1002/ana.24178. [Epub ahead of print]. 3. van Minkelen R, van Bever Y, Kromosoeto JN, et al. A clinical and genetic overview of 18 years neurofibromatosis type 1 molecular diagnostics in the Netherlands. Clin Genet. 2014 Apr;85(4):318-27. doi: 10.1111/cge.12187. Epub 2013 Jun 25. References Update September 2013 1. Abotalib Z. Preimplantation genetic diagnosis in Saudi Arabia. Bioinformation. 2013 Apr 30;9(8):388-93. Preimplantation Genetic Diagnosis Sep 15 19

2. Collins SC. Preimplantation genetic diagnosis: technical advances and expanding applications. Curr Opin Obstet Gynecol. 2013 Jun;25(3):201-6. 3. Qiao J, Wang ZB, Feng HL, et al. The root of reduced fertility in aged women and possible therapentic options: Current status and future perspects. Mol Aspects Med. 2013 Jun 21. 4. Rubio C, Bellver J, Rodrigo L, et al. Preimplantation genetic screening using fluorescence in situ hybridization in patients with repetitive implantation failure and advanced maternal age: two randomized trials. Fertil Steril. 2013 Apr;99(5):1400-7. References Update September 2012 1. Chang LJ, Chen SU, Tsai YY, et al. An update of preimplantation genetic diagnosis in gene diseases, chromosomal translocation, and aneuploidy screening. Clin Exp Reprod Med. 2011;38(3):126-134. 2. Gabbe: Obstetrics: Normal and Problem Pregnancies, 6th ed. Preimplantation Genetic Diagnosis. 2012 Saunders, An Imprint of Elsevier. 3. Harper JC, Sengupta SB. Hum Genet. 2012 Feb;131(2):175-86. Epub 2011 Jul 12. Preimplantation genetic diagnosis: state of the art 2011. 4. Lentz: Comprehensive Gynecology, 6th ed. Fertilization and early cleavage. 2012 Mosby, An Imprint of Elsevier. 5. Lubin BH, Greene MF. Collection and storage of umbilical cord blood for hematopoietic cell transplantation. March 22, 2012. UpToDate. 6. Mastenbroek S, Twisk M, van der Veen F, Repping S. Preimplantation genetic screening: A systematic review and meta-analysis of RCTs. Hum Reprod Update. 2011;17(4):454-466. 7. Musters AM, Repping S, Korevaar JC, et al. Pregnancy outcome after preimplantation genetic screening or natural conception in couples with unexplained recurrent miscarriage: A systematic review of the best available evidence. Fertil Steril. 2011;95(6):2153-2157, 2157.e1-e3. 8. Paulson R. In vitro fertilization. August 2, 2012. UpToDate. 9. Tulandi T, Al-Fozan HM. Management of couples with recurrent pregnancy loss. UpToDate. June 11, 2012. UpToDate. 10. Tur-Kaspa I. Clinical management of in vitro fertilization with preimplantation genetic diagnosis. Semin Reprod Med. 2012 Aug;30(4):309-22. Epub 2012 Jun 21. References Update October 2011 1. Colls P, Silver L, Olivera G, et al. Preimplantation genetic diagnosis for gender selection in the USA. Reprod Biomed Online. 2009;19 Suppl 2:16-22. 2. Cooper AR, Jungheim ES. Preimplantation Genetic Testing: Indications and Controversies. Clinics in Laboratory Medicine. Volume 30, Issue 3, September 2010. 3. Debrock S, Melotte C, Spiessens C, et al. Preimplantation genetic screening for aneuploidy of embryos after in vitro fertilization in women aged at least 35 years: a prospective randomized trial. Fertil Steril 2010; 93:364. 4. El-Toukhy T, Bickerstaff H, Meller S. Preimplantation genetic diagnosis for haematologic conditions. Current Opinion in Pediatrics. 2010 Feb;22(1):28-34. 5. Fischer J, Colls P, Escudero T, Munné S, et al. Preimplantation genetic diagnosis (PGD) improves pregnancy outcome for translocation carriers with a history of recurrent losses. Fertil Steril. 2010;94(1):283. 6. Harper JC, Harton G. The use of arrays in preimplantation genetic diagnosis and screening. Fertil Steril 2010; 94:1173. Preimplantation Genetic Diagnosis Sep 15 20