Does Aetna require prior authorization for CPT 45380?

No. Aetna does not list CPT 45380 on its current prior-authorization list for Standard commercial plans.

What documentation does Aetna require for CPT 45380?

Documentation requirements vary by case. Standard items include clinical notes, imaging or test results, history of conservative treatment, and a clear statement of medical necessity.

How much does Medicare pay for CPT 45380 in 2026?

In 2026, the national Medicare allowable for CPT 45380 is $479.97 in an office setting and $177.69 in a facility. Commercial allowables for Aetna are typically negotiated against this benchmark.

What if Aetna denies the PA for CPT 45380?

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 45380

Colonoscopy (lower gastrointestinal) · Standard commercial plans

No PA requiredApplies to all statesLast verified January 1, 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 does not require precertification for colonoscopy with biopsy. Covered for age-appropriate screening (45+), diagnostic evaluation of lower GI symptoms, polyp surveillance, IBD monitoring, and colorectal cancer surveillance. Facility-based colonoscopy may require site-of-service notification for some plans.

2026 Medicare rate for CPT 45380

Office (non-facility)

$479.97

Facility

$177.69

Total RVUs (office)

14.37

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 45380 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather patient history, prior conservative treatment, and clinical justification.
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 45380?: No. Aetna does not list CPT 45380 on its current prior-authorization list for Standard commercial plans.
What documentation does Aetna require for CPT 45380?: Documentation requirements vary by case. Standard items include clinical notes, imaging or test results, history of conservative treatment, and a clear statement of medical necessity.
How much does Medicare pay for CPT 45380 in 2026?: In 2026, the national Medicare allowable for CPT 45380 is $479.97 in an office setting and $177.69 in a facility. Commercial allowables for Aetna are typically negotiated against this benchmark.
What if Aetna denies the PA for CPT 45380?: 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.

Other Aetna PA lookups

CPT 17110 CPT 45378 CPT 11042 CPT 36415 CPT 20610 CPT 62323 CPT 43235 CPT 17111

All Aetna prior-authorization requirements →

CPT 45380 prior authorization by payer

Blue Cross Blue Shield Cigna Humana TRICARE Medicare Anthem

No PA needed — is Aetna paying CPT 45380 correctly?

When prior auth isn't the blocker, underpayment is. Check 45380 against the 2026 Medicare benchmark and run a free leak check — no signup.

Check 45380 payment in Ask D3 See the 45380 Medicare rate