Does Aetna require prior authorization for CPT 31297?

Yes. Aetna requires prior authorization for CPT 31297 (Sinuplasty procedures) under Standard commercial plans per its published clinical policy.

What documentation does Aetna require for CPT 31297?

Completed precertification request; Medical records requested for Aetna clinical review

How much does Medicare pay for CPT 31297 in 2026?

In 2026, the national Medicare allowable for CPT 31297 is $1564.50 in an office setting and $123.58 in a facility. Commercial allowables for Aetna are typically negotiated against this benchmark.

What if Aetna denies the PA for CPT 31297?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Aetna Prior Authorization for CPT 31297

Sinuplasty procedures · Standard commercial plans

Prior authorization REQUIREDApplies to all statesLast verified May 9, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Aetna Participating Provider Precertification List 2026 (Updated May 1, 2026)

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Aetna lists this code under Services that require precertification: Endoscopic nasal balloon dilation procedures. For commercial members, the elective procedure is also subject to medical necessity review of the procedure and site of service where marked by Aetna. Evidence: PDF p.8, Services that require precertification, item 14.

Documentation checklist

✓Completed precertification request
✓Medical records requested for Aetna clinical review

2026 Medicare rate for CPT 31297

Office (non-facility)

$1564.50

Facility

$123.58

Total RVUs (office)

46.84

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Aetna's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 31297 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Completed precertification request, Medical records requested for Aetna clinical review.
3Submit via the payer's provider portal or designated PA channel.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Aetna require prior authorization for CPT 31297?: Yes. Aetna requires prior authorization for CPT 31297 (Sinuplasty procedures) under Standard commercial plans per its published clinical policy.
What documentation does Aetna require for CPT 31297?: Completed precertification request; Medical records requested for Aetna clinical review
How much does Medicare pay for CPT 31297 in 2026?: In 2026, the national Medicare allowable for CPT 31297 is $1564.50 in an office setting and $123.58 in a facility. Commercial allowables for Aetna are typically negotiated against this benchmark.
What if Aetna denies the PA for CPT 31297?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

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