Prior Authorization
Aetna Prior Authorization for CPT 55980
Gender dysphoria treatment (regardless of diagnosis) · Standard commercial plans
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: Gender affirmation surgery. The list states listed services require precertification for members with plans applicable to the list, subject to listed exceptions. Evidence: PDF p.8, Services that require precertification, item 16.
Documentation checklist
- ✓Completed precertification request
- ✓Medical records requested for Aetna clinical review
2026 Medicare rate for CPT 55980
CPT 55980 is not priced under the 2026 Medicare Physician Fee Schedule (status C) — drugs/biologicals price under ASP and lab tests under the CLFS. See the CPT 55980 code page for pricing detail.
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 55980?
- Yes. Aetna requires prior authorization for CPT 55980 (Gender dysphoria treatment (regardless of diagnosis)) under Standard commercial plans per its published clinical policy.
- What documentation does Aetna require for CPT 55980?
- Completed precertification request; Medical records requested for Aetna clinical review
- What if Aetna denies the PA for CPT 55980?
- 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 55980 prior authorization by payer
Draft the Aetna PA request for CPT 55980 — free
Ask D3 builds a payer-ready prior-authorization request with the right criteria language and documentation — backed by CMS, Medicare, and major-payer data. No signup.