Does Aetna require prior authorization for CPT 78813?

Yes. Aetna requires prior authorization for CPT 78813 (PET scan of the full body for tumor detection) under Standard commercial plans per its published clinical policy.

What documentation does Aetna require for CPT 78813?

Completed EviCore preauthorization request; Medical records requested for delegated clinical review

What if Aetna denies the PA for CPT 78813?

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 78813

PET scan of the full body for tumor detection · 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 Special programs: Radiology imaging. The PDF states all members with plans that use this list need precertification, except inpatient facility, emergency room, or observation-bed status, and notes possible site-of-care requirements for MRI and CT scans in hospital outpatient settings. Evidence: PDF p.38, Special programs, Radiology imaging.

Documentation checklist

✓Completed EviCore preauthorization request
✓Medical records requested for delegated clinical review

Submission channels

Phone

1-888-622-7329

Fax

1-800-540-2406

2026 Medicare rate for CPT 78813

CPT 78813 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 78813 code page for pricing detail.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Completed EviCore preauthorization request, Medical records requested for delegated clinical review.
3Submit via phone or fax, or the payer portal.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Aetna require prior authorization for CPT 78813?: Yes. Aetna requires prior authorization for CPT 78813 (PET scan of the full body for tumor detection) under Standard commercial plans per its published clinical policy.
What documentation does Aetna require for CPT 78813?: Completed EviCore preauthorization request; Medical records requested for delegated clinical review
What if Aetna denies the PA for CPT 78813?: 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

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CPT 78813 prior authorization by payer

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